Nursing Elites

1. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

• A. Dry, cracked lips
• B. Bleeding gums
• C. Foul-smelling breath
• D. Red, open sores in the mouth

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

2. A nurse is reviewing the ABG results of a client with chronic emphysema. Which result suggests the need for further treatment?

• A. PaO2 level of 89 mm Hg
• B. PaCO2 level of 55 mm Hg
• C. HCO3 level of 25 mEq/L
• D. pH level of 7.37

Correct answer: B

Rationale: The correct answer is B. A PaCO2 level of 55 mm Hg is elevated, indicating carbon dioxide retention, a common complication of emphysema that necessitates intervention. Elevated PaCO2 can lead to respiratory acidosis, reflecting inadequate ventilation. Choices A, C, and D are within normal ranges. A PaO2 level of 89 mm Hg is acceptable. An HCO3 level of 25 mEq/L falls within the normal range, suggesting adequate compensation. A pH level of 7.37 is also within the normal range, indicating the client's acid-base balance is maintained.

3. A client with a permanent spinal cord injury is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?

• A. “I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a league.”
• B. “I’m glad I’ll only be in this wheelchair temporarily. I can’t wait to get back to running.”
• C. “I’m so upset that this happened to me. What did I do to deserve this, and why am I not getting better?”
• D. “I feel like I’ll never be able to do anything that I want to again. All I am is a burden to my family.”

Correct answer: A

Rationale: Choice A is the correct answer. This statement demonstrates effective coping as the client is showing acceptance of their disability and planning for the future with realistic goals. Choice B reflects denial of the permanent disability by stating that they will only be in a wheelchair temporarily. Choice C shows distress and a lack of acceptance by questioning why the injury happened and why they are not improving. Choice D indicates feelings of hopelessness and being a burden, which are not signs of effective coping.

4. A nurse is caring for a client who has been prescribed methadone. Which of the following client statements indicates a need for further teaching?

• A. I understand methadone slows my breathing.
• B. I understand methadone may cause me to have trouble sleeping.
• C. I will avoid alcohol while I’m taking this medication.
• D. I’ll change positions slowly, especially when standing.

Correct answer: B

Rationale: The correct answer is B because methadone typically causes sedation and respiratory depression, not trouble sleeping. The statement about trouble sleeping indicates a need for further teaching. Choices A, C, and D are incorrect because understanding that methadone slows breathing, avoiding alcohol while taking the medication, and changing positions slowly to prevent dizziness are all appropriate client statements when prescribed methadone.

5. A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?

• A. Increase in elasticity
• B. Decrease in pigmentation
• C. Decrease in elasticity
• D. Increase in moisture levels

Correct answer: C

Rationale: The correct answer is C: 'Decrease in elasticity.' As individuals age, they typically experience a decrease in skin elasticity, leading to sagging skin and increased wrinkles. This change in elasticity can contribute to various skin-related issues such as pressure ulcers and delayed wound healing. Choices A, B, and D are incorrect because older adults do not experience an increase in elasticity or moisture levels, and while there may be changes in pigmentation, the primary change related to aging in the integumentary system is a decrease in elasticity.

Similar Questions