Nursing Elites

1. When caring for a client with COPD, which intervention should the nurse include in the care plan?

• A. Restrict the client's fluid intake to less than 2 L/day.
• B. Encourage the client to use the upper chest for respiration.
• C. Have the client use the early-morning hours for exercise and activity.
• D. Instruct the client to use pursed-lip breathing.

Correct answer: D

Rationale: The correct answer is to instruct the client to use pursed-lip breathing. This technique helps improve breathing efficiency by keeping the airways open during exhalation and reducing air trapping. Restricting fluid intake to less than 2 L/day is not appropriate for a client with COPD, as they need adequate hydration. Using the upper chest for respiration is incorrect as it promotes shallow breathing, which is not ideal for COPD patients. While exercise is beneficial, early-morning hours may not be the best time for clients with COPD due to increased respiratory distress in the morning.

2. During a home visit, a nurse sees a client with COPD receiving oxygen at 2 L/min through a nasal cannula. The client reports difficulty breathing. What is the priority nursing action at this time?

• A. Increase the oxygen flow to 3 L/min.
• B. Evaluate the client's respiratory status.
• C. Call emergency services for the client.
• D. Instruct the client to cough and clear secretions.

Correct answer: B

Rationale: The priority nursing action in this situation is to evaluate the client's respiratory status. When a client with COPD on oxygen therapy experiences difficulty breathing, the nurse should first assess the client's respiratory status to determine the severity of the situation. Increasing the oxygen flow without proper assessment can be harmful if not clinically indicated. While calling emergency services may eventually be necessary, it should not be the immediate action without assessing the client first. Instructing the client to cough and clear secretions is not appropriate as the nurse needs to evaluate the respiratory status before proceeding with interventions.

3. A nurse in a clinic is caring for a client who came to be tested for tuberculosis (TB) after a close family member tested positive. The nurse should know that which of the following is a diagnostic tool used to screen for TB?

• A. Sputum culture for acid-fast bacillus (AFB)
• B. Mantoux skin test
• C. BCG vaccine
• D. Chest X-ray

Correct answer: B

Rationale: The Mantoux skin test, also known as the tuberculin skin test, is a diagnostic tool used to screen for tuberculosis (TB). It involves injecting a small amount of tuberculin under the top layer of the skin on the forearm and then checking for a reaction within 48-72 hours. This test helps identify individuals who have been exposed to the TB bacteria. Sputum culture for acid-fast bacillus (AFB) is used to confirm TB diagnosis in individuals suspected of having active TB. The BCG vaccine is used to prevent severe forms of tuberculosis in high-risk individuals but is not a diagnostic tool. While a chest X-ray can show signs of active TB disease, it is not a primary diagnostic tool for screening purposes.

4. A client is receiving oxygen therapy via a nasal cannula. The nurse should explain that this method of oxygen delivery does which of the following?

• A. Delivers a specific concentration of oxygen constantly
• B. Delivers a high concentration of oxygen
• C. Delivers a low concentration of oxygen
• D. Restricts the client's ability to eat, speak, or drink

Correct answer: A

Rationale: A nasal cannula is a device used for delivering supplemental oxygen to patients. It delivers a specific concentration of oxygen constantly, typically ranging from 1-6 liters per minute. This method is effective for patients who require low to moderate levels of oxygen. Choices B and C are incorrect because a nasal cannula does not deliver a high concentration of oxygen and is not considered a low concentration delivery method. Choice D is incorrect because a nasal cannula does not restrict the client's ability to eat, speak, or drink; it allows them to perform these activities while receiving oxygen therapy.

5. A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is

• A. an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.
• B. a protein whose levels reflect the risk for coronary artery disease.
• C. a heart muscle protein that appears in the bloodstream when there is damage to the heart.
• D. a protein that helps transport oxygen throughout the body.

Correct answer: C

Rationale: The correct answer is that troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a specific marker for heart muscle damage, particularly seen in conditions like myocardial infarction. Choice A is incorrect as troponin is not an enzyme that indicates damage to brain and skeletal muscle tissues. Choice B is incorrect as troponin is not a protein whose levels reflect the risk for coronary artery disease; it indicates heart muscle damage. Choice D is incorrect as troponin is not a protein that helps transport oxygen throughout the body; its presence in the bloodstream is specific to heart muscle damage.

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