Nursing Elites

1. A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?

• A. Hemoglobin: 14.2 g/dL
• B. Platelet count: 82,000/µL
• C. RBC count: 4.8 x 10^6/µL
• D. WBC count: 8.7 x 10^3/µL

Correct answer: B

Rationale: A low platelet count, as seen in choice B, is concerning as it could indicate heparin-induced thrombocytopenia, a serious side effect of heparin therapy. Heparin-induced thrombocytopenia can lead to an increased risk of blood clotting, potentially causing severe complications. Monitoring platelet counts is crucial during heparin therapy to promptly identify and manage this adverse effect.

2. A client who will undergo a bronchoscopy procedure with a rigid scope and general anesthesia will have their neck in which of the following positions?

• A. A flexed position
• B. An extended position
• C. A neutral position
• D. A hyperextended position

Correct answer: D

Rationale: During a bronchoscopy with a rigid scope and general anesthesia, the provider will typically place the client's neck in a hyperextended position to allow better visualization and access to the airways. This position helps to align the trachea for easier insertion of the scope.

3. A client with acute respiratory distress syndrome (ARDS) requires care planning. Which of the following interventions should be included in the plan?

• A. Administer low-flow oxygen continuously via nasal cannula.
• B. Encourage oral intake of at least 3,000 mL of fluids per day.
• C. Offer high-protein and high-carbohydrate foods frequently.
• D. Place in a prone position

Correct answer: D

Rationale: In acute respiratory distress syndrome (ARDS), placing the client in a prone position helps improve ventilation-perfusion matching and oxygenation. This position can optimize lung function and is a beneficial intervention for clients with ARDS. Administering low-flow oxygen via nasal cannula, encouraging oral intake of excess fluids, or offering high-protein and high-carbohydrate foods are not primary interventions for ARDS and may not directly address the respiratory distress experienced by the client.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving nutrition education. Which nutrition information should the nurse include in this client's teaching? (Select ONE that does not apply)

• A. Avoid drinking fluids just before and during meals.
• B. Rest before meals if you have dyspnea.
• C. Have about six small meals a day.
• D. Eat high-fiber foods to promote gastric emptying.

Correct answer: D

Rationale: The correct answer is D. Avoiding drinking fluids just before and during meals helps prevent bloating in clients with COPD. Resting before meals if experiencing dyspnea can aid in improving breathing during meals. Having approximately six small meals a day can reduce bloating and help with easier digestion. However, consuming high-fiber foods to promote gastric emptying is not advisable for clients with COPD, as fibrous foods can lead to gas production, abdominal bloating, and increased shortness of breath. Clients with COPD should focus on increasing calorie and protein intake to prevent malnourishment. Increasing carbohydrate intake should also be avoided, as it can raise carbon dioxide production and worsen dyspnea.

5. A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?

• A. Clamp the tube when the client is ambulating.
• B. Keep the collection device below the level of the client's chest.
• C. Carefully coil the tubes to prevent kinking.
• D. Position the client flat to avoid leaks in the tubing.

Correct answer: B

Rationale: Keeping the collection device below the level of the client's chest ensures proper drainage and prevents backflow of fluid into the patient's chest. This position allows gravity to assist in the drainage process. Clamping the tube when the client is ambulating can cause a buildup of pressure in the chest drainage system, potentially leading to complications. Carefully coiling the tubes is important to prevent obstructions and kinks that could impede the flow of drainage. Positioning the client flat may not be ideal as it could hinder proper drainage and increase the risk of leaks in the tubing.

Similar Questions