Nursing Elites

1. A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

• A. ''I will place the adapter on my finger to read my blood oxygen saturation level.''
• B. ''I will lie on my back with my knees bent.''
• C. ''I will rest my hand over my abdomen to create resistance.''
• D. ''I will take in a deep breath and hold it before exhaling.''

Correct answer: D

Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.

2. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?

• A. Oral
• B. Axillary
• C. Arterial line
• D. Rectal

Correct answer: D

Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.

3. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

• A. Ineffective airway clearance related to thick, tenacious secretions.
• B. Ineffective airway clearance related to dry, hacking cough.
• C. Ineffective individual coping with COPD.
• D. Pain related to immobilization of affected leg.

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

4. The physician orders 10 gr of aspirin for a patient. The equivalent dose in milligrams is:

• A. 0.6 mg
• B. 10 mg
• C. 60 mg
• D. 600 mg

Correct answer: D

Rationale: To convert grains (gr) to milligrams (mg), you multiply by 60. Therefore, 10 gr of aspirin is equal to 600 mg (10 gr x 60 = 600 mg). So, the correct answer is 600 mg.

5. How many liters are equal to 1800 ml?

• A. 1.8
• B. 18000
• C. 180
• D. 2800

Correct answer: A

Rationale: To convert milliliters (ml) to liters, divide by 1000 since 1 liter is equal to 1000 ml. Therefore, 1800 ml is equal to 1800/1000 = 1.8 liters. Choice A (1.8) is correct. Choice B (18000) is incorrect as it equates to 18000 liters, not 1.8 liters. Choice C (180) is incorrect as it represents 180 liters, not 1.8 liters. Choice D (2800) is incorrect as it does not reflect the conversion of 1800 ml to liters.

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