Nursing Elites

1. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following actions should the nurse take?

• A. Encourage the client to increase physical activity.
• B. Place the client in the Trendelenburg position.
• C. Limit the client's fluid intake to prevent fluid overload.
• D. Administer high-flow oxygen via mask.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with COPD is to encourage the client to increase physical activity. Increased physical activity helps manage COPD symptoms by improving lung function and preventing deconditioning. Placing the client in the Trendelenburg position is not recommended for COPD as it can worsen breathing difficulties. Limiting fluid intake to prevent fluid overload is not typically necessary in COPD unless the client has comorbid conditions that require fluid restriction. Administering high-flow oxygen via mask may be necessary for COPD clients with severe hypoxemia, but it is not the initial action for planning care.

2. What is the initial intervention for a patient with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

3. A nurse is caring for a client who has experienced intimate partner violence. What is the nurse's priority?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Contact the client's family about the incident.

Correct answer: A

Rationale: The correct answer is A: 'Develop a safety plan with the client.' When caring for a client who has experienced intimate partner violence, the nurse's priority is to ensure the client's safety. Developing a safety plan is essential to address the immediate safety concerns and provide support to the client. Referring the client to a community support group, as in option B, may be beneficial but is not the immediate priority. While determining if the client has any injuries, as in option C, is important for assessing physical well-being, the priority is to address safety concerns first. Contacting the client's family about the incident, as in option D, is not appropriate without the client's consent and may further endanger the client.

4. A nurse is caring for a client who has cirrhosis. Which of the following findings should the nurse expect?

• A. Decreased bilirubin levels
• B. Decreased prothrombin time
• C. Decreased albumin levels
• D. Increased prothrombin time

Correct answer: D

Rationale: In clients with cirrhosis, the liver is unable to produce clotting factors efficiently, leading to impaired clotting function. Therefore, an increased prothrombin time is expected in cirrhosis. Choices A, B, and C are incorrect. Decreased bilirubin levels are not typically seen in cirrhosis; prothrombin time is usually increased, not decreased; and albumin levels are often decreased in cirrhosis due to reduced synthetic liver function.

5. A nurse is providing teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?

• A. Avoid taking this medication with antacids.
• B. Contact your provider if you experience visual changes.
• C. Increase your intake of foods high in potassium.
• D. You may experience increased urination while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Contact your provider if you experience visual changes.' Visual changes, such as blurred or yellow vision, can indicate digoxin toxicity and should be reported immediately to the healthcare provider for further evaluation and management. Choice A is incorrect because digoxin can be taken with antacids. Choice C is incorrect because increasing potassium intake can lead to hyperkalemia when taking digoxin. Choice D is incorrect because increased urination is not a common side effect of digoxin.

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