Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is being taught by a nurse about measures to improve breathing. Which of the following instructions should the nurse include?

• A. Use pursed-lip breathing during physical activity
• B. Breathe deeply and quickly during exercise
• C. Avoid using the incentive spirometer
• D. Avoid physical activity to conserve energy

Correct answer: A

Rationale: The correct instruction the nurse should include is to 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a technique that helps improve breathing efficiency in individuals with COPD by preventing airway collapse and allowing for better air exchange. Choice B is incorrect because breathing deeply and quickly can lead to hyperventilation and worsen symptoms in COPD patients. Choice C is incorrect because the incentive spirometer is a device used to encourage deep breathing and improve lung function, so it should not be avoided. Choice D is incorrect because physical activity is important for maintaining overall health and should be encouraged in a controlled and appropriate manner for individuals with COPD.

2. A client with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?

• A. Use a phenol solution to clean the wound
• B. Place a warm compress over the wound
• C. Cleanse the wound from the center outwards
• D. Administer antibiotics prophylactically

Correct answer: C

Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.

3. What is the priority intervention when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Administer sedative medication to control agitation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.

4. A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?

• A. Offer medical advice
• B. Offer general leads
• C. Ask open-ended questions
• D. Use assertive communication

Correct answer: B

Rationale: In the context of establishing a trusting relationship with a client who has major depressive disorder, offering general leads is the most appropriate communication technique. General leads encourage clients to express themselves by providing subtle prompts or cues, which can help build rapport and trust. Offering medical advice (Choice A) is not suitable as it may come across as imposing and could hinder the establishment of trust. Asking open-ended questions (Choice C) is beneficial for eliciting detailed responses but may not be as effective at initially establishing trust as general leads. Using assertive communication (Choice D) can be perceived as aggressive and intimidating, which is not conducive to building a trusting relationship with a client who has major depressive disorder.

5. What is the role of the nurse in postoperative care for a patient with a hip replacement?

• A. Monitor for signs of infection and administer pain relief
• B. Ensure the patient follows a low-calcium diet
• C. Ensure the patient uses crutches to avoid pressure on the hip
• D. Monitor for signs of deep vein thrombosis

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of infection and administer pain relief. In postoperative care for a patient with a hip replacement, it is crucial for the nurse to monitor for signs of infection, such as increased pain, redness, swelling, or drainage from the surgical site. Administering pain relief is also important to ensure the patient's comfort and aid in their recovery. Choices B, C, and D are incorrect as they do not directly relate to the immediate postoperative care needs of a patient with a hip replacement. Ensuring a low-calcium diet, using crutches, or monitoring for deep vein thrombosis are not primary responsibilities in the immediate postoperative period for this type of surgery.

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