Nursing Elites

1. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?

• A. Avoid physical activity
• B. Use pursed-lip breathing during activities
• C. Limit sun exposure
• D. Perform weight-bearing exercises

Correct answer: B

Rationale: The correct answer is B: 'Use pursed-lip breathing during activities.' Pursed-lip breathing improves oxygenation by keeping airways open longer, facilitating better exhalation of carbon dioxide. Choice A is incorrect because avoiding physical activity can lead to deconditioning and worsen oxygenation. Choice C is irrelevant to improving oxygenation in COPD. Choice D is not directly related to improving oxygenation in COPD; weight-bearing exercises are important for bone health but not for oxygenation.

2. A client with a new diagnosis of diabetes mellitus needs instruction on foot care. What advice should the nurse provide?

• A. Soak feet in warm water daily
• B. Wear shoes at all times
• C. Cut toenails in a rounded shape
• D. Inspect the feet weekly

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes at all times.' This instruction is crucial for clients with diabetes as it helps protect the feet from potential injuries. Choice A of soaking feet in warm water daily can lead to skin issues and should be avoided. Cutting toenails in a rounded shape, as mentioned in choice C, can increase the risk of ingrown toenails. While inspecting the feet weekly, as in choice D, is important, wearing shoes at all times is a more preventative measure to avoid foot injuries in diabetic clients.

3. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

• A. Frequent repositioning
• B. Poor nutrition
• C. Increased fluid intake
• D. Use of a special mattress

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

4. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Palpate the abdomen before auscultation
• B. Inspect the abdomen after palpation
• C. Auscultate before palpation
• D. Start by percussing the abdomen

Correct answer: C

Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.

5. A nurse is caring for a client who reports pain and burning around the peripheral IV site. What is the nurse's priority action?

• A. Apply a warm compress
• B. Discontinue the IV line
• C. Increase the IV flow rate
• D. Elevate the limb

Correct answer: B

Rationale: The correct answer is B: Discontinue the IV line. When a client reports pain and burning around the peripheral IV site, it indicates possible phlebitis, which is inflammation of the vein. The priority action is to discontinue the IV line to prevent further complications such as infection or thrombosis. Applying a warm compress (Choice A) may worsen the inflammation. Increasing the IV flow rate (Choice C) can exacerbate the symptoms and elevate the risk of complications. Elevating the limb (Choice D) may provide comfort, but it does not address the underlying issue of phlebitis. Therefore, the priority action is to discontinue the IV line.

Similar Questions