Nursing Elites

1. A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?

• A. Perform chest physiotherapy every 4 hours.
• B. Suction the client every 2 hours.
• C. Encourage the client to increase fluid intake.
• D. Administer oxygen via nasal cannula.

Correct answer: C

Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.

2. A healthcare provider is caring for a client who has a new prescription for enoxaparin. Which of the following actions should the healthcare provider take?

• A. Administer the medication intramuscularly.
• B. Inject the medication into the client's abdomen.
• C. Massage the injection site after administration.
• D. Aspirate for blood return before administering.

Correct answer: B

Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously into the abdomen to ensure proper absorption. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice C is incorrect because massaging the injection site after administration is not recommended for enoxaparin injections. Choice D is incorrect because aspirating for blood return is not necessary before administering a subcutaneous injection like enoxaparin.

3. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse identify as an indication of the effectiveness of the treatment?

• A. Respiratory rate of 24/min
• B. White blood cell count of 15,000/mm3
• C. SpO2 of 95%
• D. Clear breath sounds

Correct answer: D

Rationale: Clear breath sounds are an essential indicator of effective pneumonia treatment as they suggest resolution of the lung infection. A normal respiratory rate (A) indicates adequate breathing but does not directly reflect the effectiveness of pneumonia treatment. An elevated white blood cell count (B) is a sign of infection and may not decrease immediately with treatment. While maintaining an SpO2 of 95% (C) is crucial for oxygenation, it may not directly indicate the effectiveness of pneumonia treatment.

4. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect?

• A. Loose stools.
• B. Jitteriness.
• C. Hypertonia.
• D. Abdominal distention.

Correct answer: B

Rationale: Corrected Rationale: Jitteriness is a common manifestation of hypoglycemia in newborns. Choice A, 'Loose stools,' is not typically associated with hypoglycemia in newborns. Choice C, 'Hypertonia,' is not a common manifestation of hypoglycemia in newborns; instead, hypotonia may be observed. Choice D, 'Abdominal distention,' is not a typical manifestation of hypoglycemia in newborns.

5. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

• A. Barrel-shaped chest
• B. Bradycardia
• C. Increased respiratory rate
• D. Tracheal deviation

Correct answer: C

Rationale: Corrected Rationale: An increased respiratory rate is a common finding in clients with ARDS as the body attempts to compensate for impaired gas exchange. Barrel-shaped chest (Choice A) is associated with conditions like COPD, not ARDS. Bradycardia (Choice B) is unlikely in ARDS due to the body's compensatory mechanisms to improve oxygenation. Tracheal deviation (Choice D) is not typically seen in ARDS and is more suggestive of other respiratory conditions.

Similar Questions