Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?

• A. Reposition the nasal cannula
• B. Lower the oxygen rate
• C. Encourage the client to cough and deep breathe
• D. Monitor the client's oxygen saturation level

Correct answer: B

Rationale: In this scenario, the client with COPD receiving increased oxygen is experiencing oxygen toxicity, leading to lethargy and confusion. Lowering the oxygen rate is the priority action to prevent further harm. Repositioning the nasal cannula, encouraging coughing and deep breathing, and monitoring oxygen saturation are all important interventions, but the immediate concern is to address the oxygen toxicity by lowering the oxygen rate.

2. When preparing an educational program for adolescents about the risks of multiple sexual partners, which information is most important to include?

• A. Condoms provide reliable protection against sexually transmitted infections.
• B. Having multiple sexual partners increases the risk of contracting sexually transmitted infections.
• C. The use of oral contraceptives can reduce the risk of sexually transmitted infections.
• D. Having multiple sexual partners increases the risk of developing cancer.

Correct answer: B

Rationale: The correct answer is B because having multiple sexual partners significantly increases the risk of contracting sexually transmitted infections (STIs). This information is crucial for adolescents to understand the potential consequences of engaging in risky sexual behaviors. Choice A is incorrect because while condoms are important for protection, they are not 100% effective. Choice C is incorrect as oral contraceptives do not protect against STIs. Choice D is incorrect as the immediate concern for adolescents in this context is the risk of STIs rather than cancer.

3. A 7-year-old with cystic fibrosis (CF) has received instructions about home care. Which statement made by the child's mother indicates that further teaching is needed?

• A. My child should not have a cough at all times
• B. He needs to take pancreatic enzymes with meals and snacks
• C. He needs to use a bronchodilator every day
• D. His dietary intake needs to be high in protein and calories

Correct answer: A

Rationale: The correct answer is A. A cough at all times is not normal in a child with cystic fibrosis (CF) and indicates the need for further teaching on CF management. Choices B, C, and D are correct statements in managing CF: taking pancreatic enzymes with meals and snacks, using a bronchodilator daily, and maintaining a high-protein and high-calorie dietary intake are all appropriate for a child with CF.

4. A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?

• A. Bladder distention
• B. Serum albumin level
• C. Abdominal girth
• D. Breath sounds

Correct answer: D

Rationale: The correct answer is 'D. Breath sounds.' When a client receiving amlodipine develops edema, it is crucial to assess for potential heart failure, a side effect of the medication. Checking breath sounds helps in identifying any signs of pulmonary edema, a severe complication of heart failure. Choices A, B, and C are less relevant in this context. Bladder distention could be associated with urinary issues, serum albumin level with malnutrition or liver disease, and abdominal girth with gastrointestinal problems, none of which directly relate to the potential heart failure induced by amlodipine.

5. The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?

• A. Activity tolerance as evidenced by appropriate age-level activities being performed
• B. Absence of skin breakdown as evidenced by intact skin and absence of redness
• C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
• D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr

Correct answer: D

Rationale: In acute glomerulonephritis, maintaining fluid balance is the priority to prevent complications like fluid overload or dehydration. Monitoring urine output within the range of 1 to 2 ml/kg/hr is crucial in assessing renal function. While activity tolerance, skin integrity, and nutritional status are important aspects of care, fluid balance takes precedence due to its direct impact on the renal condition and overall health outcome for the child.

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