Nursing Elites

1. A client has a hemoglobin level of 7 g/dL. Which of the following findings should the nurse expect?

• A. Bounding pulses
• B. Elevated blood pressure
• C. Headache
• D. Pale, cool skin

Correct answer: D

Rationale: Pale, cool skin is a common finding in clients with a hemoglobin level of 7 g/dL due to decreased oxygen carrying capacity. Bounding pulses (Choice A) are not typically associated with low hemoglobin levels. Elevated blood pressure (Choice B) is not a common finding in clients with anemia. While headache (Choice C) can occur with anemia, it is not a specific finding directly related to a hemoglobin level of 7 g/dL.

2. A client with multiple sclerosis and dysphagia requires care. Which intervention should the nurse include in the plan?

• A. Position the client supine with the head of the bed flat.
• B. Have the client tuck their chin while swallowing.
• C. Provide the client with thickened liquids.
• D. Place the food on the unaffected side of the mouth.

Correct answer: C

Rationale: For clients with dysphagia, especially those with multiple sclerosis, thin liquids can increase the risk of aspiration. Thickened liquids are recommended to reduce the risk of aspiration and help with swallowing difficulties. Positioning the client supine with the head of the bed flat can further increase the risk of aspiration. Having the client tuck their chin while swallowing is a strategy used for some types of dysphagia but not specifically for multiple sclerosis-related dysphagia. Placing food on the unaffected side of the mouth does not address the swallowing difficulties associated with dysphagia.

3. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

4. A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Blood pressure 110/70 mm Hg
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: A low urine output of 20 mL/hr, less than the expected 30 mL/hr or more, could indicate renal impairment or inadequate fluid status postoperatively. In this scenario, early detection and intervention are crucial to prevent further complications. The other findings - heart rate of 88/min, pain rating of 4, and blood pressure of 110/70 mm Hg - are within normal limits for a client 2 hr postoperative following an inguinal hernia repair and do not raise immediate concerns.

5. A nurse is providing discharge teaching to a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?

• A. You should take this medication at bedtime.
• B. You might experience palpitations while taking this medication.
• C. You should rinse your mouth after using this medication.
• D. You should avoid eating before taking this medication.

Correct answer: C

Rationale: The correct answer is C: 'You should rinse your mouth after using this medication.' When providing discharge teaching for a client prescribed albuterol, the nurse should include the instruction to rinse the mouth after each use. This is important to prevent dry mouth and oral infections. Choice A is incorrect as albuterol is usually taken during the day to manage symptoms, not at bedtime. Choice B is incorrect as palpitations are not a common side effect of albuterol. Choice D is incorrect as there is no specific requirement to avoid eating before taking albuterol.

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