Nursing Elites

1. A client with COPD is receiving home oxygen therapy. Which instruction is most important for the nurse to include in the discharge teaching?

• A. Increase oxygen flow rate during physical activity
• B. Smoke at least 10 feet away from the oxygen source
• C. Use petroleum jelly to prevent nasal dryness
• D. Ensure the oxygen tank is stored in a secure upright position

Correct answer: D

Rationale: The most important instruction for the nurse to include in the discharge teaching for a client with COPD receiving home oxygen therapy is to ensure the oxygen tank is stored in a secure upright position. This is crucial to prevent accidents such as leaks or falls that can lead to serious injury or damage. Choice A is incorrect as increasing the oxygen flow rate during physical activity without a healthcare provider's guidance can be harmful. Choice B is incorrect as smoking near an oxygen source can cause a fire hazard. Choice C is incorrect as petroleum jelly is flammable and should not be used around oxygen due to the risk of combustion.

2. What are the clinical manifestations of otitis media?

• A. Earache, wheezing, vomiting
• B. Coughing, rhinorrhea, headache
• C. Fever, irritability, pulling on ear
• D. Wheezing, cough, drainage in ear canal

Correct answer: C

Rationale: The correct answer is C: Fever, irritability, pulling on the ear. Clinical manifestations of otitis media commonly include fever, irritability, and children may show signs of pulling or rubbing their ears. Choices A, B, and D are incorrect. Choice A includes wheezing and vomiting, which are not typical symptoms of otitis media. Choice B includes coughing, rhinorrhea, and headache, which are more commonly associated with upper respiratory infections rather than otitis media. Choice D includes wheezing, cough, and drainage in the ear canal, which are not typical clinical manifestations of otitis media.

3. What could suddenly occur in a child with acute epiglottitis?

• A. Increased carbon dioxide levels
• B. Airway obstruction
• C. Inability to swallow
• D. Bronchial collapse

Correct answer: B

Rationale: In acute epiglottitis, the infected epiglottis becomes inflamed and can lead to sudden airway obstruction, which is a life-threatening emergency. This can cause difficulty breathing and necessitates immediate intervention to secure the airway. Increased carbon dioxide levels may occur due to inadequate ventilation resulting from airway obstruction, but the primary concern is the obstruction itself, not the carbon dioxide levels. Inability to swallow may be present due to pain and swelling in the throat but is not the immediate life-threatening complication associated with acute epiglottitis. Bronchial collapse is not a typical consequence of acute epiglottitis.

4. Based on the interpretation of this strip, what action should be implemented first?

• A. Call a code.
• B. Start CPR.
• C. Administer IV fluids.
• D. Apply oxygen.

Correct answer: A

Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.

5. Which signs/symptoms would be considered classical signs of meningeal irritation?

• A. Positive Kernig sign, diarrhea, and headache
• B. Negative Brudzinski sign, positive Kernig sign, and irritability
• C. Positive Brudzinski sign, positive Kernig sign, and photophobia
• D. Negative Kernig sign, vomiting, and fever

Correct answer: C

Rationale: The correct answer is C: Positive Brudzinski sign, positive Kernig sign, and photophobia are considered classical signs of meningeal irritation. The Kernig sign is positive when the leg is extended at the knee and then raised, resulting in pain and resistance. The Brudzinski sign is positive when flexing the neck causes flexion of the hips and knees due to meningeal irritation. Photophobia, or sensitivity to light, is a common symptom due to meningeal inflammation. Choices A, B, and D are incorrect because they do not include the classic signs associated with meningeal irritation.

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