Nursing Elites

1. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD) who is prescribed home oxygen. Which of the following statements should the nurse make?

• A. Check your oxygen equipment daily for proper function.
• B. Increase the oxygen flow rate if you feel short of breath.
• C. Store your oxygen tanks lying flat on the floor.
• D. It is safe to smoke as long as you are more than 10 feet from the oxygen source.

Correct answer: A

Rationale: The correct statement for the nurse to make is to advise the client to check the oxygen equipment daily for proper function. This is crucial to ensure the client's home oxygen therapy is working effectively and safely. Choice B is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored upright, not lying flat. Choice D is incorrect and unsafe advice, as smoking near an oxygen source can lead to a fire hazard.

2. A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?

• A. Keep the head of the bed elevated to 30 degrees.
• B. Administer IV antibiotics prophylactically.
• C. Change the catheter insertion site every 24 hours.
• D. Monitor the insertion site for redness.

Correct answer: D

Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.

3. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Cleanse the wound with povidone-iodine solution daily.
• B. Irrigate the wound with hydrogen peroxide.
• C. Reposition the client every 4 hours.
• D. Apply a moisture barrier ointment.

Correct answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.

4. A nurse is teaching a client who has chronic kidney disease about managing protein intake. Which of the following statements should the nurse include in the teaching?

• A. You should consume more plant-based protein.
• B. You should increase your intake of animal protein.
• C. You should increase your intake of high-protein foods.
• D. You should limit your intake of high-protein foods.

Correct answer: D

Rationale: The correct answer is D: "You should limit your intake of high-protein foods." Clients with chronic kidney disease should reduce their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Choices A, B, and C are incorrect because increasing intake of either plant-based or animal protein or high-protein foods can exacerbate kidney issues in individuals with chronic kidney disease.

5. Which lab value is critical for patients on warfarin therapy?

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

Correct answer: A

Rationale: The correct answer is to monitor INR levels for patients on warfarin therapy. INR monitoring is essential because it helps assess the clotting tendency of the blood and ensures that patients are within the therapeutic range to prevent both blood clots and excessive bleeding. Monitoring potassium levels (Choice B), sodium levels (Choice C), or platelet count (Choice D) is not specifically required for patients on warfarin therapy and does not directly impact the effectiveness or safety of the medication.

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