Nursing Elites

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

• A. Encourage the client to increase fluid intake.
• B. Suction the client every 2 hours.
• C. Perform chest physiotherapy every 8 hours.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

2. A healthcare provider is caring for a client who has been diagnosed with sepsis. Which of the following laboratory results indicates that the client is developing disseminated intravascular coagulation (DIC)?

• A. Elevated hemoglobin
• B. Elevated white blood cell count
• C. Decreased fibrinogen level
• D. Decreased platelet count

Correct answer: D

Rationale: The correct answer is D, decreased platelet count. In disseminated intravascular coagulation (DIC), there is widespread activation of clotting factors leading to the formation of multiple blood clots throughout the body, which can deplete platelets. A decreased platelet count is a hallmark of DIC. Elevated hemoglobin (choice A) and elevated white blood cell count (choice B) are not specific indicators of DIC. While fibrinogen levels (choice C) can be decreased in DIC due to consumption, a decreased platelet count is a more specific and early sign of DIC development.

3. Which lab value is most critical to monitor in a patient receiving insulin therapy?

• A. Monitor blood glucose
• B. Monitor potassium levels
• C. Monitor calcium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor blood glucose levels. When a patient is receiving insulin therapy, it is crucial to monitor blood glucose levels regularly to prevent hypoglycemia, a potential side effect of insulin therapy. Monitoring potassium, calcium, or sodium levels is important for different medical conditions or treatments and is not directly related to insulin therapy.

4. A nurse is caring for a client with heart failure receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate 60/min.
• B. Blood pressure 110/70 mm Hg.
• C. Serum potassium 4 mEq/L.
• D. Blood pressure 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.

5. A client scheduled for a thoracentesis requires assistance from a nurse. Which of the following actions should the nurse take?

• A. Assist the client to a prone position.
• B. Assist the client to a sitting position.
• C. Assist the client to a supine position.
• D. Assist the client to a lateral position.

Correct answer: B

Rationale: The correct answer is to assist the client to a sitting position. Placing the client in a sitting position helps facilitate easier access during the thoracentesis procedure by allowing gravity to assist in the removal of pleural fluid. Placing the client in a prone, supine, or lateral position would not provide the optimal positioning needed for a thoracentesis and could make the procedure more challenging or uncomfortable for the client.

Similar Questions