Nursing Elites

1. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 92%
• B. Use of pursed-lip breathing
• C. Increased anterior-posterior chest diameter
• D. Productive cough with green sputum

Correct answer: D

Rationale: The correct answer is D. A productive cough with green sputum can indicate a bacterial infection, which is a concern for clients with COPD. Reporting this finding to the provider is important for further evaluation and management. Choices A, B, and C are not as concerning in the context of COPD management. An oxygen saturation of 92% is within an acceptable range for COPD patients, pursed-lip breathing is a helpful technique for managing breathing difficulties in COPD, and an increased anterior-posterior chest diameter is a common finding in clients with COPD due to chronic air trapping.

2. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is the best predictor of future violence as individuals who have a history of violent behavior are more likely to engage in violent acts in the future. While experiencing delusions and being male may contribute to an increased risk of violence in certain situations, they are not as strong predictors as a history of violence. Similarly, having a history of being in prison may indicate a higher likelihood of violence, but it is not as directly linked to future violent behavior as previous violent actions.

3. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of furosemide. Which of the following findings indicates the nurse should increase the client's infusion rate?

• A. Urine output of 20 mL/hr
• B. Heart rate of 90/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1 kg in 24 hr

Correct answer: D

Rationale: A weight gain of 1 kg in 24 hours can indicate fluid retention and worsening heart failure, requiring an increase in diuresis. This finding suggests that the current diuretic therapy is not effective enough to manage the fluid overload, necessitating an increase in the infusion rate of furosemide. Choices A, B, and C are not directly related to the need for an increase in diuretic therapy in heart failure patients. Urine output of 20 mL/hr, a heart rate of 90/min, and a sodium level of 138 mEq/L are important parameters to monitor but do not specifically indicate the need to increase the infusion rate of furosemide.

4. A nurse is caring for a client who is receiving continuous enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

• A. Administer the feeding using a large-bore syringe
• B. Check the placement of the tube every 8 hours
• C. Flush the tube with 5 mL of water every 6 hours
• D. Maintain the client in an upright position

Correct answer: B

Rationale: The correct action for the nurse to take is to check the placement of the nasogastric tube every 8 hours. This is crucial to ensure that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Administering the feeding using a large-bore syringe (Choice A) is not recommended for enteral nutrition. Flushing the tube with water every 6 hours (Choice C) is not necessary for continuous enteral nutrition. Maintaining the client in an upright position (Choice D) is generally preferred to reduce the risk of aspiration, but it is not the most critical action compared to verifying tube placement.

5. A nurse is caring for a client who is receiving radiation therapy. Which of the following side effects should the nurse monitor for?

• A. Fatigue
• B. Hair loss
• C. Nausea
• D. Dry mouth

Correct answer: D

Rationale: The correct answer is D, dry mouth. Dry mouth is a common side effect of radiation therapy due to damage to the salivary glands. It is essential for the nurse to monitor for this condition as it can lead to oral health issues and discomfort. Fatigue (choice A) is a common side effect of radiation therapy, but in this case, dry mouth is a more specific side effect to monitor for. Hair loss (choice B) is more commonly associated with chemotherapy rather than radiation therapy. Nausea (choice C) is also a common side effect of radiation therapy, but dry mouth is a more direct effect of the treatment that the nurse should focus on monitoring.

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