Nursing Elites

1. A client with COPD expresses concerns about leaving the house due to continuous oxygen use. What is an appropriate response by the nurse?

• A. There are portable oxygen delivery systems that you can take with you.
• B. When you go out, you can remove the oxygen and then reapply it when you get home.
• C. You probably will not be able to go out as much as you used to.
• D. Home health services will come to see you so you will not need to get out.

Correct answer: A

Rationale: For a client with COPD concerned about leaving the house while on continuous oxygen, the nurse should provide reassurance by mentioning the availability of portable oxygen delivery systems. These systems allow the client to maintain their oxygen therapy while being mobile, enabling them to go out and engage in activities outside the home. This response promotes independence and quality of life for the client, addressing their immediate concerns and offering a practical solution to their perceived limitation.

2. Before rigor mortis occurs, what is the nurse responsible for?

• A. Providing a complete bath and dressing change
• B. Placing one pillow under the body’s head and shoulders
• C. Removing the body’s clothing and wrapping the body in a shroud
• D. Allowing the body to relax normally

Correct answer: B

Rationale: Before rigor mortis occurs, the nurse is responsible for placing a pillow under the body's head and shoulders. This action helps maintain proper positioning, prevent postmortem changes, and ensure a dignified appearance. Providing a complete bath and dressing change, removing clothing, or wrapping the body in a shroud are tasks typically performed after rigor mortis sets in or later in the postmortem care process. Allowing the body to relax normally does not address the immediate need for proper positioning before rigor mortis occurs.

3. The healthcare professional is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?

• A. Oral
• B. Axillary
• C. Radial
• D. Heat-sensitive tape

Correct answer: A

Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely. Axillary temperature may be affected by environmental factors, while radial temperature measurement is not a standard method for assessing core body temperature. Heat-sensitive tape is not a recognized method for assessing body temperature in clinical practice.

4. All of the following interventions are correct when using the Z-track method of drug injection except:

• A. Prepare the injection site with alcohol
• B. Use a needle that is at least 1” long
• C. Aspirate for blood before injection
• D. Rub the site vigorously after the injection to promote absorption

Correct answer: D

Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1” long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.

5. Which of the following is the correct abbreviation for drops?

• A. Gtt.
• B. Gtts.
• C. Dp.
• D. Dr.

Correct answer: A

Rationale: The correct abbreviation for drops in medical terminology is 'Gtt.' It is derived from the Latin word 'guttae,' meaning drops. The abbreviation 'Gtts.' (Choice B) is incorrect as it adds an unnecessary 's.' Choices C and D, 'Dp.' and 'Dr.,' are not standard abbreviations for drops in medical contexts, making them incorrect.

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