Nursing Elites

1. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?

• A. Nutritional status
• B. Client's response to pain medication
• C. Daily vital signs
• D. Most recent lab results

Correct answer: B

Rationale: The correct answer is B: Client's response to pain medication. When transferring a client to another unit, it is crucial to communicate how the client is responding to pain medication to ensure continuity of care and appropriate pain management. While nutritional status, daily vital signs, and most recent lab results are important aspects of the client's care, the client's response to pain medication directly impacts their comfort and well-being during the transfer process.

2. A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?

• A. Apply lotion between the toes after bathing
• B. Inspect feet daily for injuries
• C. Wear shoes only indoors
• D. Cut toenails in a rounded shape

Correct answer: B

Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.

3. A healthcare professional is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. What finding should the healthcare professional expect?

• A. Decreased respiratory rate
• B. Flushing of the skin
• C. Flaring of the nostrils
• D. Productive cough

Correct answer: C

Rationale: Flaring of the nostrils is a sign of increased respiratory effort, which is common in clients with COPD experiencing dyspnea. Choices A, B, and D are incorrect. A decreased respiratory rate is not expected in a client with COPD experiencing dyspnea, as they often have an increased respiratory rate. Flushing of the skin is not a typical finding associated with COPD or dyspnea. While a productive cough can be seen in COPD, it is not specifically related to the increased respiratory effort seen with dyspnea.

4. A nurse is providing discharge teaching to a client who has a prescription for home oxygen therapy. What should the nurse teach?

• A. Remove the oxygen tubing during meals
• B. Wear synthetic fabrics while using oxygen
• C. Use cotton fabrics when oxygen is in use
• D. Increase oxygen flow during physical activity

Correct answer: C

Rationale: The correct answer is C: 'Use cotton fabrics when oxygen is in use.' When a client is on oxygen therapy, it is essential to use cotton fabrics to reduce the risk of static electricity, which can ignite in the presence of oxygen. Choices A, B, and D are incorrect. Removing the oxygen tubing during meals is not necessary as long as proper precautions are taken to avoid tripping hazards. Synthetic fabrics should be avoided while using oxygen therapy to prevent static electricity buildup. Increasing oxygen flow during physical activity should be done according to the healthcare provider's instructions, not indiscriminately.

5. A nurse is preparing to administer enteral feedings to a client with a nasogastric (NG) tube. What action should the nurse take first?

• A. Measure the residual gastric volume
• B. Verify tube placement
• C. Flush the tube with 100 mL of water
• D. Administer the feeding in small boluses

Correct answer: B

Rationale: Verifying tube placement is the crucial initial step a nurse should take before administering enteral feedings through an NG tube. This step ensures that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Measuring residual gastric volume, flushing the tube with water, or administering the feeding in small boluses are all important steps in enteral feeding but should only be done after confirming the correct tube placement.

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