Nursing Elites

1. A nurse is planning to teach a group of clients about preventing low back pain. Which of the following information should the nurse include?

• A. Wear low-heeled shoes.
• B. Elevate the legs while sitting.
• C. Engage in prolonged sitting to rest the back muscles.
• D. Sleep on a soft mattress to prevent strain on the back.

Correct answer: A

Rationale: The correct answer is A: 'Wear low-heeled shoes.' Wearing low-heeled shoes helps prevent back strain by promoting proper posture. High heels can cause an imbalance in the body's alignment, leading to increased stress on the lower back. Choices B, C, and D are incorrect. Elevating the legs while sitting can help with circulation but does not directly prevent low back pain. Engaging in prolonged sitting can actually contribute to low back pain due to decreased muscle activity and increased pressure on the spine. Sleeping on a soft mattress may not provide adequate support for the back, potentially worsening back pain instead of preventing it.

2. What is the priority nursing action for a patient with respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

3. During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. The client's oxygen saturation is 95%
• B. The client's blood pressure is 110/70 mm Hg
• C. The client has a temperature of 36.8°C (98.2°F)
• D. The client's heart rate is 88/min

Correct answer: B

Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.

4. What is the most critical lab value to monitor for a patient on heparin therapy?

• A. Monitor aPTT levels
• B. Monitor platelet count
• C. Monitor INR levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT levels. Activated Partial Thromboplastin Time (aPTT) is crucial for assessing the therapeutic effectiveness of heparin, as it reflects the intrinsic pathway of the coagulation cascade. Monitoring aPTT helps ensure that the patient is within the therapeutic range of heparin, minimizing the risk of bleeding complications. Platelet count (choice B) is important to assess for potential heparin-induced thrombocytopenia but is not the primary lab value to monitor during heparin therapy. INR levels (choice C) are monitored in patients on warfarin therapy, not heparin. Sodium levels (choice D) are not directly related to heparin therapy monitoring.

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

• A. Take one puff every 5 minutes until symptoms improve.
• B. Hold your breath for 10 seconds after inhaling the medication.
• C. Shake the inhaler for 2 seconds before use.
• D. Exhale forcefully after each puff.

Correct answer: B

Rationale: The correct answer is B. Instructing the client to hold their breath for 10 seconds after inhaling the medication allows it to reach deeper into the lungs for maximum effectiveness. Choice A is incorrect because taking one puff every 5 minutes may lead to overuse of the medication. Choice C is incorrect as shaking the inhaler for only 2 seconds may not provide adequate mixing of the medication. Choice D is incorrect because exhaling forcefully after each puff may reduce the amount of medication that reaches the lungs.

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