Nursing Elites

1. A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?

• A. Decreased breath sounds on the affected side
• B. Hyperresonance on percussion of the affected side
• C. Increased tactile fremitus on the affected side
• D. Tracheal deviation toward the affected side

Correct answer: A

Rationale: In a client with pleural effusion, decreased breath sounds on the affected side are common due to the presence of fluid in the pleural space. Hyperresonance is not expected; dullness on percussion is more likely. Tactile fremitus is typically decreased, not increased, in pleural effusion cases. Tracheal deviation away from the affected side, not toward it, can be seen with large effusions.

2. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?

• A. Since many of your family members are carriers, your children will also be carriers of the gene.
• B. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
• C. Since you have a family history of cystic fibrosis, I would encourage you & your partner to be tested.
• D. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.

Correct answer: C

Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.

3. A client with dyspnea and difficulty climbing stairs is classified as having class III dyspnea. Which intervention should the nurse include in the client's plan of care?

• A. Assistance with activities of daily living.
• B. Daily physical therapy activities.
• C. Oxygen therapy at 2 liters per nasal cannula.
• D. Complete bedrest with frequent repositioning.

Correct answer: A

Rationale: Class III dyspnea indicates significant limitations in activity due to shortness of breath. Clients with this level of dyspnea should be encouraged to participate in activities within their tolerance levels. Providing assistance with activities of daily living helps conserve energy for essential tasks while promoting independence. Oxygen therapy is only necessary if hypoxia is present, and complete bedrest is generally not recommended for clients with dyspnea unless specifically indicated.

4. A healthcare professional assesses a client's respiratory status. Which information is of highest priority for the healthcare professional to obtain?

• A. Average daily fluid intake
• B. Neck circumference
• C. Height & weight
• D. Occupation & hobbies

Correct answer: D

Rationale: Obtaining information about a client's occupation and hobbies is crucial when assessing respiratory status as many respiratory problems can result from chronic exposure to inhalation irritants related to these activities. Understanding the client's potential exposure can help the healthcare professional identify risk factors and provide appropriate interventions to promote respiratory health.

5. A client is scheduled for a colonoscopy and receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?

• A. I can have clear liquids up to 2 hours before the procedure.
• B. I need to take a laxative the night before the procedure.
• C. I will be sedated during the procedure.
• D. I should avoid eating solid foods for 24 hours before the procedure.

Correct answer: D

Rationale: The correct answer is D because clients are typically instructed to avoid solid foods for 12-24 hours before a colonoscopy, not a full 24 hours. This statement indicates a need for further teaching to ensure the client follows the correct dietary instructions for the procedure.

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