Nursing Elites

1. A healthcare professional is caring for a client who has an arteriovenous fistula. Which of the following findings should the healthcare professional report?

• A. Thrill upon palpation.
• B. Absence of a bruit.
• C. Distended blood vessels.
• D. Swishing sound upon auscultation.

Correct answer: B

Rationale: The correct answer is B: Absence of a bruit. In a client with an arteriovenous fistula, the presence of a bruit (a humming sound) is an expected finding due to the high-pressure flow of blood through the fistula. Therefore, the absence of a bruit suggests a complication, such as thrombosis or stenosis, which should be reported for further evaluation and management. Choices A, C, and D are incorrect because a thrill upon palpation, distended blood vessels, and a swishing sound upon auscultation are expected findings in a client with an arteriovenous fistula and do not necessarily indicate a complication.

2. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to breathe deeply and cough every 4 hours.
• B. Provide a diet that is high in carbohydrates and low in protein.
• C. Teach the client pursed-lip breathing technique.
• D. Restrict the client's fluid intake to 1,500 mL per day.

Correct answer: C

Rationale: The correct answer is C: Teach the client pursed-lip breathing technique. Pursed-lip breathing helps clients with COPD improve oxygenation and reduce shortness of breath. Choice A is incorrect because deep breathing and coughing are not recommended every 4 hours for clients with COPD. Choice B is incorrect because a diet high in carbohydrates and low in protein is not specifically indicated for COPD. Choice D is incorrect because fluid restriction is not a standard intervention for COPD unless the client has comorbid conditions that necessitate it.

3. A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect?

• A. Increased urine output
• B. Increased serum sodium
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: C

Rationale: In clients with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse should expect hyponatremia. SIADH leads to excess water retention, diluting the sodium levels in the blood, resulting in low serum sodium levels. Choice A, increased urine output, is incorrect as SIADH causes water retention, leading to decreased urine output. Choice B, increased serum sodium, is incorrect because SIADH causes a dilutional effect due to water retention, resulting in decreased serum sodium levels. Choice D, hypercalcemia, is unrelated to SIADH and not a typical finding.

4. A nurse is assessing a client who has a chest tube and notes continuous bubbling in the water seal chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client.
• B. Clamp the chest tube.
• C. Replace the drainage system.
• D. Apply a dressing over the insertion site.

Correct answer: D

Rationale: The correct action for the nurse to take when continuous bubbling is noted in the water seal chamber of a chest tube is to apply a dressing over the insertion site. Continuous bubbling indicates an air leak, and applying a dressing helps manage this issue by providing a seal. Clamping the chest tube or replacing the drainage system is not appropriate in this situation as it can lead to complications such as tension pneumothorax or inadequate drainage of the pleural space.

5. A client is receiving chemotherapy and is being taught about preventing infection. Which of the following instructions should the nurse include?

• A. Take your temperature daily.
• B. Avoid fresh fruits and vegetables.
• C. Limit your intake of high-protein foods.
• D. Increase your intake of high-fat foods.

Correct answer: B

Rationale: Clients receiving chemotherapy are instructed to avoid fresh fruits and vegetables to lower the risk of infection. Fresh produce may harbor bacteria or other pathogens that could be harmful to individuals with compromised immune systems. Taking the temperature daily may be important but is not directly related to preventing infection. Limiting high-protein foods is not necessary unless there are specific dietary restrictions due to the treatment plan. Increasing the intake of high-fat foods is not recommended during chemotherapy as a high-fat diet may lead to other health issues.

Similar Questions