Nursing Elites

1. A nurse is providing discharge instructions to a client with home oxygen therapy. Which of the following is essential for safety?

• A. Allow the client to smoke in designated outdoor areas
• B. Place the oxygen equipment 10 feet away from any open flames
• C. Keep oxygen tanks upright at all times
• D. Restrict fluid intake while using oxygen

Correct answer: C

Rationale: The correct answer is to keep oxygen tanks upright at all times. This is essential for safety as it prevents the tanks from falling and causing injury. Allowing the client to smoke in designated outdoor areas (Choice A) is unsafe as smoking near oxygen equipment can lead to a fire. Placing the oxygen equipment 10 feet away from any open flames (Choice B) is important to prevent fire hazards, but keeping the tanks upright is more directly related to preventing injuries. Restricting fluid intake while using oxygen (Choice D) is not necessary for safety in home oxygen therapy.

2. A client who is postpartum is being taught about breast care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will wear tight-fitting bras to reduce discomfort
• B. I will nurse my baby frequently to prevent engorgement
• C. I will pump my breasts every 4 hours
• D. I will avoid nursing for at least 48 hours

Correct answer: B

Rationale: The correct answer is B. Nursing the baby frequently helps prevent engorgement and discomfort in breastfeeding mothers. Choice A is incorrect because tight-fitting bras can lead to clogged milk ducts and worsen discomfort. Choice C may lead to oversupply issues and is not necessary unless there is a specific indication. Choice D is incorrect as avoiding nursing for extended periods can lead to engorgement and decreased milk supply.

3. A nurse is reinforcing teaching about a clear liquid diet. What should the client avoid?

• A. Lemon-lime sports drinks
• B. Orange sherbet
• C. Black coffee
• D. Ginger ale

Correct answer: D

Rationale: The correct answer is D, Ginger ale. A clear liquid diet includes fluids that are see-through and easily digestible. Ginger ale is a carbonated beverage that is allowed on a clear liquid diet. Orange sherbet, choice B, is not suitable for a clear liquid diet as it contains dairy products and solid particles, which are not transparent. Lemon-lime sports drinks, choice A, may contain added colorings or particles that are not allowed on a clear liquid diet. Black coffee, choice C, is also not recommended on a clear liquid diet as it is not a clear liquid and contains substances that may be hard to digest.

4. When should a healthcare provider suction a client's tracheostomy?

• A. When the client is hypotensive
• B. When the client is irritable
• C. When the client is flushed
• D. When the client is bradycardic

Correct answer: B

Rationale: Irritability is an early sign that suctioning is required to clear secretions in a client with a tracheostomy. Hypotension, flushing, and bradycardia are not direct indicators for suctioning a tracheostomy. Hypotension may indicate a need for fluid resuscitation or other interventions, flushing could be due to various reasons like fever, and bradycardia may require evaluation for cardiac causes.

5. What are the early signs and symptoms of sepsis?

• A. Increased heart rate and fever
• B. Low blood pressure and confusion
• C. Rapid breathing and sweating
• D. Abdominal pain and cyanosis

Correct answer: A

Rationale: The correct answer is A: Increased heart rate and fever. In sepsis, an increased heart rate and fever are common early signs of systemic infection. While choices B, C, and D can be present in later stages of sepsis, they are not typically the initial signs. Low blood pressure and confusion may occur in severe sepsis or septic shock. Rapid breathing and sweating can be seen as sepsis progresses. Abdominal pain and cyanosis may develop as the condition advances but are not usually the earliest signs.

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