Nursing Elites

1. A nurse at a provider's office is reinforcing teaching with a client who is being treated with chemotherapy and is losing weight. Which of the following instructions should the nurse give to increase the client's caloric intake? (Select one that doesn't apply).

• A. Top yogurt with granola.
• B. Use honey on toast.
• C. Use milk instead of water in recipes.
• D. Increase fluids during meals.

Correct answer: D

Rationale: Increasing fluids during meals does not directly contribute to increasing caloric intake. Topping yogurt with granola, using honey on toast, and using milk instead of water in recipes are effective ways to boost caloric intake. While adequate fluid intake is important for hydration and overall health, it does not address the specific need to increase caloric intake in this scenario.

2. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?

• A. Nausea and vomiting
• B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
• C. Diffuse macular rash
• D. Muscle tenderness

Correct answer: B

Rationale: A high fever, such as 103 degrees Fahrenheit (39.5 degrees Celsius), in a client with infective endocarditis indicates that the infection may not be responding to the antibiotics and requires immediate medical evaluation. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically associated with the ineffectiveness of antibiotic therapy in infective endocarditis.

3. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain a sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw the catheter in a circular motion

Correct answer: A

Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.

4. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A. Sensory perceptual alterations related to decreased vision
• B. Alteration in mobility related to fatigue
• C. Impaired gas exchange related to retained secretions
• D. Altered patterns of urinary elimination related to nocturia

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

5. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which of these actions should the nurse perform first?

• A. Administer oxygen therapy
• B. Encourage the client to perform deep breathing exercises
• C. Raise the head of the bed
• D. Check the client's oxygen saturation level

Correct answer: D

Rationale: The correct answer is to check the client's oxygen saturation level first. This action is crucial in assessing the severity of dyspnea and determining the necessity for oxygen therapy. Administering oxygen therapy without knowing the current oxygen saturation level can be inappropriate and potentially harmful. Encouraging deep breathing exercises and raising the head of the bed are important interventions, but assessing the oxygen saturation level takes precedence in managing dyspnea in a client with COPD.

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