Nursing Elites

1. A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

• A. Increase dietary intake of raw vegetables
• B. Limit activity
• C. Drink four to five glasses of water daily
• D. Bear down hard when defecating

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to drink four to five glasses of water daily. Increasing water intake helps alleviate constipation by softening stool and increasing bowel movements. Choice A, increasing dietary intake of raw vegetables, can be helpful in preventing constipation but may not be sufficient as the sole intervention for someone already experiencing constipation. Choice B, limiting activity, can worsen constipation as physical activity helps stimulate bowel movements. Choice D, bearing down hard when defecating, can lead to other issues like hemorrhoids and should be avoided.

2. While working the night shift, a nurse observes a colleague behaving strangely. What is the best course of action?

• A. Ignore the behavior and continue working
• B. Report the behavior to the supervisor
• C. Ask the colleague if everything is okay
• D. Discuss the behavior with other colleagues

Correct answer: B

Rationale: When a nurse observes a colleague behaving strangely, the best course of action is to report the behavior to the supervisor. Unusual behavior by a healthcare professional could compromise patient safety and should be addressed promptly. Ignoring the behavior (Choice A) could potentially lead to negative outcomes for patients. Asking the colleague directly (Choice C) may not be appropriate if the behavior poses a risk. Discussing the behavior with other colleagues (Choice D) may not directly address the issue and could lead to gossip rather than a resolution.

3. How should a healthcare professional manage a patient with a chest tube?

• A. Ensuring the chest tube is secured properly and functioning
• B. Checking for air leaks and ensuring drainage is working
• C. Ensuring chest tube drainage is below chest level
• D. Ensuring proper documentation of chest tube output

Correct answer: D

Rationale: Proper documentation of chest tube output is crucial in the care of a patient with a chest tube. While ensuring the chest tube is secured and functioning, checking for air leaks, and maintaining drainage below chest level are important aspects of care, documentation of output is essential for monitoring the patient's condition, assessing the effectiveness of treatment, and ensuring appropriate interventions if needed.

4. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

• A. Administer a diuretic as prescribed.
• B. Place the patient in a high Fowler's position.
• C. Administer oxygen via nasal cannula.
• D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

5. A healthcare provider is reviewing the laboratory report of a client who is receiving heparin therapy for a deep vein thrombosis. Which of the following lab values indicates a therapeutic response to the therapy?

• A. PT of 12 seconds
• B. aPTT of 70 seconds
• C. Platelets of 150,000/mm3
• D. INR of 1.5

Correct answer: B

Rationale: An aPTT of 70 seconds is within the therapeutic range for a client receiving heparin therapy. The activated partial thromboplastin time (aPTT) is the most sensitive test to monitor heparin therapy. A therapeutic aPTT range for a client receiving heparin is usually 1.5 to 2.5 times the control value. Choices A, C, and D are not indicators of a therapeutic response to heparin therapy. PT measures the extrinsic pathway of coagulation and is not specific to monitoring heparin therapy. Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not indicate the therapeutic response to heparin therapy. INR is used to monitor warfarin therapy, not heparin therapy.

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