Nursing Elites

1. A provider is discharging a client with a prescription for home oxygen therapy. Client and family teaching by the nurse should include all of the following instructions except?

• A. Cleanse the mask or collar with soapy water every other day.
• B. Ensure that the straps on the mask are secure but not too tight.
• C. Apply petroleum jelly around and inside the nares.
• D. Post 'no smoking' warning signs at home in a prominent location.

Correct answer: C

Rationale: When providing instructions for home oxygen therapy, it is important to ensure safety and proper care. Choices A, B, and D are all essential instructions for the client and family. Choice C, 'Apply petroleum jelly around and inside the nares,' is incorrect. Petroleum jelly should not be used near oxygen sources as it is flammable and can increase the risk of fire hazard. Therefore, this instruction should not be included in the teaching.

2. A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is

• A. an enzyme that indicates damage to brain, heart, and skeletal muscle tissues.
• B. a protein whose levels reflect the risk for coronary artery disease.
• C. a heart muscle protein that appears in the bloodstream when there is damage to the heart.
• D. a protein that helps transport oxygen throughout the body.

Correct answer: C

Rationale: The correct answer is that troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a specific marker for heart muscle damage, particularly seen in conditions like myocardial infarction. Choice A is incorrect as troponin is not an enzyme that indicates damage to brain and skeletal muscle tissues. Choice B is incorrect as troponin is not a protein whose levels reflect the risk for coronary artery disease; it indicates heart muscle damage. Choice D is incorrect as troponin is not a protein that helps transport oxygen throughout the body; its presence in the bloodstream is specific to heart muscle damage.

3. A client who is HIV-positive, has pneumonia and is not responding to antibiotic therapy may have active pulmonary tuberculosis (TB) due to exposure history and symptoms of night sweats and hemoptysis. Which test is the most reliable to confirm the diagnosis of active pulmonary TB?

• A. Chest x-ray
• B. Presence of bronchophony
• C. Mantoux test
• D. Sputum culture for acid-fast bacillus

Correct answer: D

Rationale: The correct answer is D: Sputum culture for acid-fast bacillus. The most reliable test to confirm the diagnosis of active pulmonary TB is the sputum culture for acid-fast bacillus. This test helps identify the presence of Mycobacterium tuberculosis, the causative agent of TB, in the sputum. Chest x-rays can show characteristic findings of TB but are not as reliable as sputum cultures for confirmation. Bronchophony is a test for assessing vocal resonance and is not specific for TB diagnosis. The Mantoux test is a screening test for TB exposure but cannot confirm active disease.

4. During a home visit, a nurse sees a client with COPD receiving oxygen at 2 L/min through a nasal cannula. The client reports difficulty breathing. What is the priority nursing action at this time?

• A. Increase the oxygen flow to 3 L/min.
• B. Evaluate the client's respiratory status.
• C. Call emergency services for the client.
• D. Instruct the client to cough and clear secretions.

Correct answer: B

Rationale: The priority nursing action in this situation is to evaluate the client's respiratory status. When a client with COPD on oxygen therapy experiences difficulty breathing, the nurse should first assess the client's respiratory status to determine the severity of the situation. Increasing the oxygen flow without proper assessment can be harmful if not clinically indicated. While calling emergency services may eventually be necessary, it should not be the immediate action without assessing the client first. Instructing the client to cough and clear secretions is not appropriate as the nurse needs to evaluate the respiratory status before proceeding with interventions.

5. A client is receiving oxygen therapy via a nasal cannula. The nurse should explain that this method of oxygen delivery does which of the following?

• A. Delivers a specific concentration of oxygen constantly
• B. Delivers a high concentration of oxygen
• C. Delivers a low concentration of oxygen
• D. Restricts the client's ability to eat, speak, or drink

Correct answer: A

Rationale: A nasal cannula is a device used for delivering supplemental oxygen to patients. It delivers a specific concentration of oxygen constantly, typically ranging from 1-6 liters per minute. This method is effective for patients who require low to moderate levels of oxygen. Choices B and C are incorrect because a nasal cannula does not deliver a high concentration of oxygen and is not considered a low concentration delivery method. Choice D is incorrect because a nasal cannula does not restrict the client's ability to eat, speak, or drink; it allows them to perform these activities while receiving oxygen therapy.

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