Nursing Elites

1. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following should the nurse assess for?

• A. Respiratory rate
• B. Chest pain
• C. Use of accessory muscles
• D. Oxygen saturation

Correct answer: C

Rationale: In a client with COPD, the nurse should assess for the use of accessory muscles. This is important because COPD can lead to increased work of breathing, causing the client to engage accessory muscles to help with respiration. Assessing for the use of accessory muscles provides crucial information about the client's respiratory effort. Respiratory rate (Choice A) is a standard assessment parameter but may not specifically indicate the severity of COPD. Chest pain (Choice B) is not typically associated with COPD unless there are complicating factors. Oxygen saturation (Choice D) is essential to monitor in COPD clients, but assessing for the use of accessory muscles takes priority as it directly reflects the client's respiratory status in COPD.

2. A home health nurse is providing teaching to a patient who has a new diagnosis of a gastric ulcer and a new prescription for sucralfate oral suspension. What statement by the patient indicates an understanding of the teaching?

• A. I will take this medicine with meals.
• B. I will take this medicine right before bed.
• C. I will take this medicine 1 hour before meals and at bedtime.
• D. I will take this medicine only when I have symptoms.

Correct answer: C

Rationale: The correct answer is C because sucralfate should be taken on an empty stomach, 1 hour before meals, and at bedtime to coat the ulcer and protect it from stomach acid. Choice A is incorrect because taking it with meals may reduce its effectiveness. Choice B is incorrect as it should not be taken right before bed. Choice D is incorrect as sucralfate should be taken regularly as prescribed, not just when symptoms occur.

3. A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client's membranes have ruptured?

• A. Nonstress test
• B. Biophysical profile
• C. Fern test
• D. Amniocentesis

Correct answer: C

Rationale: The correct answer is the Fern test. The Fern test is specifically used to confirm the rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid. The Nonstress test (Choice A) is used to monitor fetal heart rate and movement, not to confirm ruptured membranes. The Biophysical profile (Choice B) is a prenatal ultrasound evaluation to assess fetal well-being, not to confirm ruptured membranes. Amniocentesis (Choice D) involves the aspiration of amniotic fluid for various diagnostic purposes, not specifically to confirm ruptured membranes.

4. While caring for a newborn under phototherapy lights, what is an appropriate nursing action?

• A. Ensure an eye shield is covering the eyes
• B. Apply lotion to the exposed skin
• C. Offer glucose water between feedings
• D. Discontinue breastfeeding during treatment

Correct answer: A

Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.

5. A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?

• A. I should wear my slippers whenever I am out of bed
• B. I can walk barefoot at home
• C. I should apply lotion between my toes
• D. I can soak my feet in warm water

Correct answer: A

Rationale: The correct answer is A. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it protects the feet from injury. Walking barefoot, as mentioned in option B, can increase the risk of cuts, sores, and infections in diabetic patients. Applying lotion between the toes, as stated in option C, can lead to maceration and increase the risk of fungal infections. Similarly, soaking feet in warm water, as mentioned in option D, can cause skin breakdown and should be avoided by diabetic patients.

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