Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Encourage pursed-lip breathing.
• B. Administer oxygen at 6 L/min via nasal cannula.
• C. Place the client in a supine position.
• D. Restrict fluid intake to less than 1,500 mL/day.

Correct answer: A

Rationale: Encouraging pursed-lip breathing is essential for clients with COPD as it aids in improving ventilation and gas exchange. This technique helps keep the airways open longer during exhalation, preventing air trapping and promoting more effective breathing. Administering oxygen, placing the client in a supine position, or restricting fluid intake are not primary interventions for managing COPD and may not address the specific respiratory needs of the client.

2. During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?

• A. What is your marital status?
• B. How would you describe yourself?
• C. Are you employed?
• D. Do you have any children?

Correct answer: B

Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.

3. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

4. A client with a new diagnosis of anemia is being taught about dietary management. Which of the following statements should be included in the teaching?

• A. You should increase your intake of foods high in iron.
• B. You should decrease your intake of foods high in calcium.
• C. You should avoid foods that contain gluten.
• D. You should increase your intake of high-fat foods.

Correct answer: A

Rationale: The correct answer is A: 'You should increase your intake of foods high in iron.' This statement should be included in the teaching because increasing intake of foods high in iron is essential for managing anemia. Iron is a key component for producing hemoglobin, which carries oxygen in the blood. By increasing iron-rich foods like leafy greens, red meat, and fortified cereals, the client can help improve their hemoglobin levels and overall health. Choices B, C, and D are incorrect. Decreasing intake of foods high in calcium is not necessary for anemia management; avoiding foods that contain gluten is relevant for individuals with gluten sensitivity or celiac disease, not anemia; and increasing intake of high-fat foods is not recommended for managing anemia.

5. Which of the following statements indicates the client understands the colostomy care instructions?

• A. I will change the colostomy bag once a week.
• B. I will avoid eating high-fiber foods.
• C. I will clean around the stoma with mild soap and water.
• D. I will apply lotion to the skin around the stoma.

Correct answer: C

Rationale: The correct answer is C. Cleaning around the stoma with mild soap and water is crucial for colostomy care as it helps prevent infection and skin irritation. Changing the colostomy bag frequency, dietary modifications, or applying lotion are not primary aspects of stoma care. Proper cleaning around the stoma helps maintain hygiene and prevents complications, making it a key component of caring for a colostomy.

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