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. After delivering a healthy newborn, a client is experiencing postpartum hemorrhage. What initial intervention should the nurse implement?

• A. Administer IV fluids
• B. Perform a uterine massage
• C. Monitor the newborn's vital signs
• D. Notify the healthcare provider

Correct answer: B

Rationale: The correct initial intervention for postpartum hemorrhage is to perform a uterine massage. This action helps the uterus contract, controlling bleeding. Administering IV fluids may be necessary but is not the initial intervention. Monitoring the newborn's vital signs is important but not the priority when managing postpartum hemorrhage. Notifying the healthcare provider can be done after initiating immediate interventions to address the hemorrhage.

3. What is the primary purpose of a chest tube in a client's care?

• A. To drain air and fluid from the pleural space
• B. To prevent infection in the thoracic cavity
• C. To assist with lung expansion
• D. To monitor intrathoracic pressure

Correct answer: A

Rationale: The correct answer is A: To drain air and fluid from the pleural space. A chest tube is primarily used to remove accumulated air or fluid in the pleural space, preventing lung collapse or compromise of lung function. This intervention aims to re-expand the lung and enhance respiratory function. Choice B is incorrect because preventing infection is not the primary purpose of a chest tube. Choice C is incorrect as lung expansion is a result of draining the pleural space, not the primary goal. Choice D is incorrect as monitoring intrathoracic pressure is not the main objective of a chest tube insertion.

4. A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?

• A. Hyperkalemia.
• B. Hyponatremia.
• C. Hypocalcemia.
• D. Hypokalemia.

Correct answer: D

Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.

5. A client with diabetes mellitus is scheduled for surgery. What is the most important preoperative instruction the nurse should provide?

• A. Take your insulin as usual
• B. Do not eat or drink after midnight
• C. Monitor your blood glucose closely
• D. Bring your glucose meter to the hospital

Correct answer: B

Rationale: The most important preoperative instruction for a client with diabetes mellitus scheduled for surgery is to instruct them not to eat or drink after midnight. This instruction is crucial to maintain NPO (nothing by mouth) status before surgery, reducing the risk of aspiration during anesthesia. While taking insulin as usual (Choice A) is important, doses can be adjusted by the healthcare team. Monitoring blood glucose closely (Choice C) is essential but not as critical preoperatively. Bringing a glucose meter to the hospital (Choice D) can be helpful but is not as vital as maintaining NPO status.

Similar Questions