Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?

• A. Increase the oxygen flow rate according to the prescription
• B. Encourage the client to perform pursed-lip breathing
• C. Prepare for emergency intubation
• D. Assess the client's oxygen saturation and breath sounds

Correct answer: D

Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.

2. The nurse is preparing a client for discharge following a myocardial infarction. What should the nurse prioritize in the discharge instructions?

• A. Warning signs of a potential heart attack
• B. Importance of medication adherence
• C. Follow-up appointment details
• D. All of the above

Correct answer: D

Rationale: When preparing a client for discharge after a myocardial infarction, the nurse should prioritize providing comprehensive instructions. This includes educating the client about warning signs of a potential heart attack to recognize symptoms early, stressing the importance of medication adherence for optimal recovery and prevention of further cardiac events, and ensuring understanding of follow-up appointment details for ongoing monitoring and care. All these aspects are crucial in preventing complications and promoting the client's well-being. Therefore, selecting 'All of the above' as the correct answer is the most appropriate choice. Choices A, B, and C are all essential components of a holistic discharge plan for a client post-myocardial infarction.

3. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?

• A. Assess the client's hemoglobin levels to determine if the client is in shock
• B. Call the surgeon and prepare to take the client back to the operating room
• C. Outline the area with ink and check it every 15 minutes to monitor for changes in bleeding
• D. No action is required as postoperative bleeding can be expected

Correct answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

4. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?

• A. Place tape from the cheek to the forehead
• B. Secure tape from the nose to the ear
• C. Attach tape from the lower eyelid to the upper forehead
• D. Use circular bandaging around the head

Correct answer: C

Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.

5. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?

• A. Dry mucous membranes
• B. Increased urine output
• C. Tachycardia
• D. Hypotension

Correct answer: B

Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.

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