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. Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for the treatment of herpes zoster (shingles)?

• A. Initiate cardiac telemetry monitoring
• B. Maintain continuous pulse oximetry
• C. Perform capillary glucose measurements
• D. Monitor serum creatinine levels

Correct answer: D

Rationale: The correct answer is to monitor serum creatinine levels. Acyclovir can potentially impact kidney function, making it essential to monitor serum creatinine levels to assess renal function. Option A, initiating cardiac telemetry monitoring, is not directly related to acyclovir administration for herpes zoster. Option B, maintaining continuous pulse oximetry, is more relevant in assessing respiratory status rather than monitoring for acyclovir-related side effects. Option C, performing capillary glucose measurements, is not directly associated with acyclovir therapy for herpes zoster.

3. The nurse is planning care for a client receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?

• A. Administer an antiemetic before meals
• B. Provide frequent mouth care
• C. Encourage small, frequent meals
• D. Offer clear liquids

Correct answer: A

Rationale: Administering an antiemetic before meals is a crucial intervention to manage chemotherapy-induced nausea. Antiemetics help prevent or reduce nausea and vomiting associated with chemotherapy. Providing frequent mouth care (choice B) is important for managing oral mucositis but not specifically for nausea. Encouraging small, frequent meals (choice C) and offering clear liquids (choice D) are beneficial strategies for managing gastrointestinal side effects but may not be as effective in controlling nausea as administering antiemetics.

4. Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia?

• A. A young adult client with intractable vomiting due to food poisoning
• B. A client who developed hyperparathyroidism in late adolescence
• C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
• D. A female client who excessively consumes simple carbohydrates

Correct answer: C

Rationale: The correct answer is C. Clients in renal failure are at high risk for hypomagnesemia due to their impaired kidney function. Renal failure can lead to decreased excretion of magnesium, resulting in its buildup in the body and potential hypomagnesemia. This client requires careful nursing assessment for signs and symptoms of hypomagnesemia to prevent complications. Choices A, B, and D are not as directly associated with renal failure and its impact on magnesium levels. Intractable vomiting, hyperparathyroidism, and excessive consumption of simple carbohydrates may have other health implications but are not as strongly linked to hypomagnesemia as renal failure.

5. When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?

• A. I will use crutches to keep my weight off my knee
• B. I will stay home until a wheelchair is delivered
• C. I can use the trapeze bar and side rails on the bed to help me turn regularly
• D. I can put my full weight on my foot starting the day after surgery

Correct answer: A

Rationale: The correct answer is A. Using crutches indicates an understanding of weight-bearing restrictions post-surgery. Choice B is incorrect because waiting for a wheelchair is not related to postoperative mobility instructions. Choice C is incorrect as turning in bed using the trapeze bar and side rails does not address weight-bearing restrictions. Choice D is incorrect because putting full weight on the foot immediately after surgery contradicts the need to keep weight off the knee.

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