Nursing Elites

1. A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan?

• A. Experiences occasional heartburn after eating spicy food
• B. Consumes 10 or more drinks of alcohol every weekend
• C. Reports frequent use of NSAIDs
• D. Has a history of peptic ulcers

Correct answer: B

Rationale: Excessive alcohol consumption is a major risk factor for gastritis and should be prioritized in the teaching plan. While spicy foods and NSAIDs can contribute to gastritis, alcohol consumption is the most significant factor that needs immediate lifestyle changes to prevent worsening of gastritis symptoms. Peptic ulcers, although relevant, are not as directly linked to exacerbating gastritis symptoms as alcohol consumption.

2. A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?

• A. Auscultate the bowel sounds.
• B. Palpate the ankles for edema.
• C. Observe the skin for bruising.
• D. Measure the body temperature.

Correct answer: A

Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.

3. Which intervention should be included in the long-term plan of care for a client with COPD?

• A. Administer high-flow oxygen during sleep.
• B. Reduce risk factors for infection.
• C. Limit fluid intake to reduce secretions.
• D. Use diaphragmatic breathing to achieve better exhalation.

Correct answer: D

Rationale: The correct answer is D: 'Use diaphragmatic breathing to achieve better exhalation.' Diaphragmatic breathing is an essential intervention for clients with COPD as it helps improve exhalation and lung function, ultimately reducing symptoms over the long term. Option A is incorrect because high-flow oxygen during sleep is more relevant for clients with conditions like sleep apnea rather than COPD. Option B, 'Reduce risk factors for infection,' is important but not as specific to the long-term management of COPD as diaphragmatic breathing. Option C, 'Limit fluid intake to reduce secretions,' is not a recommended intervention for clients with COPD, as adequate hydration is crucial for maintaining respiratory health.

4. A client with emphysema reports shortness of breath. What is the nurse's priority action?

• A. Administer oxygen therapy.
• B. Assess the client’s respiratory rate and effort.
• C. Prepare the client for intubation.
• D. Increase the client's oxygen flow rate.

Correct answer: B

Rationale: Shortness of breath in a client with emphysema may indicate respiratory distress. Assessing the client’s respiratory rate and effort is the first priority to determine the severity of the distress and guide appropriate interventions. Administering oxygen therapy (Choice A) could be necessary, but assessing the client first is crucial to tailor the intervention. Intubation (Choice C) is an invasive procedure that is not the initial priority. Increasing oxygen flow rate (Choice D) should only be done after a thorough assessment to avoid potential harm.

5. Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect?

• A. Reduced cardiac output
• B. Disrupted surfactant production
• C. Hyperactivity of alveoli
• D. Increased oxygen carrying capacity

Correct answer: B

Rationale: Corrected Rationale: Prolonged exposure to high oxygen concentrations can disrupt the production of surfactant in the lungs, leading to atelectasis and other lung complications. Surfactant is essential for maintaining lung compliance and preventing alveolar collapse. Reduced cardiac output (Choice A) is not directly associated with prolonged oxygen exposure. Hyperactivity of alveoli (Choice C) is not a recognized consequence of high oxygen levels. Increased oxygen carrying capacity (Choice D) is not a pathophysiological effect of prolonged high oxygen exposure.

Similar Questions