Nursing Elites

1. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

• A. Use a donut-shaped cushion for sitting
• B. Turn the client every 4 hours
• C. Elevate the head of the bed to 45 degrees
• D. Massage reddened areas to increase circulation

Correct answer: C

Rationale: Elevating the head of the bed reduces pressure on bony prominences, which helps prevent pressure ulcers.

2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose level of 150 mg/dL
• B. Serum sodium level of 138 mEq/L
• C. Serum potassium level of 3.0 mEq/L
• D. Serum albumin level of 3.8 g/dL

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.0 mEq/L is below the normal range and indicates hypokalemia, which should be reported to the provider. Hypokalemia can lead to serious complications such as cardiac arrhythmias. Choices A, B, and D are within normal ranges and do not require immediate reporting. A blood glucose level of 150 mg/dL is slightly elevated but not critically high. A serum sodium level of 138 mEq/L is within the normal range. A serum albumin level of 3.8 g/dL is also within the normal range.

3. 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.

4. A healthcare provider is assessing a client who has COPD and is receiving oxygen therapy at 2 L/min via nasal cannula. Which of the following findings should the provider report?

• A. Oxygen saturation of 95%.
• B. Productive cough with clear sputum.
• C. Respiratory rate of 22/min.
• D. Client reports dyspnea.

Correct answer: D

Rationale: The correct answer is D. Dyspnea in a client with COPD receiving oxygen should be reported as it may indicate worsening respiratory status. Oxygen saturation of 95% is within the expected range for a client receiving oxygen therapy and does not require immediate reporting. A productive cough with clear sputum is a common symptom in clients with COPD and does not necessarily warrant urgent reporting. A respiratory rate of 22/min is also within normal limits and does not raise immediate concerns in this scenario.

5. A client with a nasogastric tube receiving intermittent enteral feedings should be positioned in which way?

• A. Flush the tube with 15 mL of sterile water before feedings.
• B. Place the client in a supine position during feedings.
• C. Position the client with the head of the bed elevated 45 degrees.
• D. Check gastric residuals every 8 hours.

Correct answer: C

Rationale: Positioning the client with the head of the bed elevated at 45 degrees is crucial during enteral feedings to prevent aspiration. This position helps reduce the risk of regurgitation and aspiration of feedings into the lungs. Option A is not necessary before feedings. Placing the client in a supine position (Option B) increases the risk of aspiration. Checking gastric residuals every 8 hours (Option D) is important but not directly related to positioning during enteral feedings.

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