Nursing Elites

1. A healthcare provider is assessing a client who has COPD and is receiving oxygen therapy at 2 L/min via nasal cannula. Which of the following findings should the provider report?

• A. Oxygen saturation of 95%.
• B. Productive cough with clear sputum.
• C. Respiratory rate of 22/min.
• D. Client reports dyspnea.

Correct answer: D

Rationale: The correct answer is D. Dyspnea in a client with COPD receiving oxygen should be reported as it may indicate worsening respiratory status. Oxygen saturation of 95% is within the expected range for a client receiving oxygen therapy and does not require immediate reporting. A productive cough with clear sputum is a common symptom in clients with COPD and does not necessarily warrant urgent reporting. A respiratory rate of 22/min is also within normal limits and does not raise immediate concerns in this scenario.

2. A healthcare provider is reviewing the laboratory data of a client who is receiving total parenteral nutrition. Which of the following findings should the healthcare provider report?

• A. Serum calcium 8.5 mg/dL
• B. Blood glucose level 120 mg/dL
• C. Serum sodium 138 mEq/L
• D. Serum albumin 3.5 g/dL

Correct answer: D

Rationale: The correct answer is D: Serum albumin 3.5 g/dL. A low serum albumin level indicates protein deficiency, which can be a complication of TPN therapy and requires prompt intervention. The other laboratory findings provided (serum calcium 8.5 mg/dL, blood glucose level 120 mg/dL, and serum sodium 138 mEq/L) are within normal ranges and do not specifically indicate complications related to TPN therapy.

3. A client with gastroesophageal reflux disease (GERD) is being taught about dietary management by a nurse. Which of the following instructions should the nurse include?

• A. Avoid eating spicy foods.
• B. Eat three large meals each day.
• C. Lie down after meals.
• D. Increase your intake of dairy products.

Correct answer: A

Rationale: The correct instruction for a client with GERD is to avoid eating spicy foods. Spicy foods can trigger GERD symptoms by irritating the esophagus and increasing acid reflux. Choices B, C, and D are incorrect. Eating three large meals each day can exacerbate GERD symptoms by putting pressure on the lower esophageal sphincter, lying down after meals can worsen reflux due to gravity, and increasing dairy product intake may lead to higher fat consumption, which can also trigger GERD symptoms.

4. What is the best intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Apply compression stockings
• C. Encourage ambulation
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The best intervention for a patient with suspected deep vein thrombosis (DVT) is to administer anticoagulants. Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Applying compression stockings can help manage symptoms but does not address the underlying issue of clot formation. Encouraging ambulation is beneficial for overall circulation but may not be sufficient to treat DVT. Monitoring oxygen saturation is important, but it is not the primary intervention for suspected DVT.

5. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?

• A. Dry mucous membranes
• B. Polyuria
• C. Epistaxis
• D. Diarrhea

Correct answer: C

Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.

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