Nursing Elites

1. An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)

• A. Monitor electrolyte levels.
• B. Maintain pulse oximetry.
• C. Provide assistance with mobility.
• D. All of the Above

Correct answer: D

Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.

2. The nurse is caring for a client with myasthenia gravis. Which symptom is most important for the nurse to report to the healthcare provider?

• A. Diplopia (double vision)
• B. Difficulty swallowing
• C. Weakness in the legs
• D. Fatigue

Correct answer: B

Rationale: In a client with myasthenia gravis, difficulty swallowing is the most crucial symptom to report to the healthcare provider. This is because it can lead to aspiration, a severe complication in these clients. Diplopia (double vision) and weakness in the legs are common symptoms of myasthenia gravis but are not as immediately dangerous as difficulty swallowing. Fatigue is also a common symptom in myasthenia gravis but does not pose the same risk of aspiration as difficulty swallowing.

3. The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat Gout?

• A. I need to take the prescribed amount of the drug to get rid of my gout.
• B. I need to take this drug every day to keep from having any flare-ups.
• C. I should take this drug when I have gout attacks to reduce symptoms.
• D. The pain and swelling can be controlled by taking this drug every day.

Correct answer: B

Rationale: Taking allopurinol every day helps to prevent gout flare-ups by reducing uric acid levels.

4. How often should the casts be changed for a newborn with talipes who is wearing casts?

• A. Daily
• B. Weekly
• C. Biweekly
• D. Monthly

Correct answer: B

Rationale: The correct answer is B: Weekly. Treatment of talipes involves manipulation and applying short leg casts. The casts need to be changed weekly to allow for further manipulation and to accommodate the rapid growth of the infant. Changing the casts daily (choice A) would be too frequent and may not provide enough time for the correction to take place. Changing the casts biweekly (choice C) or monthly (choice D) would not provide adequate support for the ongoing correction process required for talipes.

5. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?

• A. Avoid coiling the tubing and keep it free of kinks.
• B. Cleanse the perineal area with soap and water twice daily.
• C. Keep the drainage bag lower than the level of the bladder.
• D. Drink 1,000 ml of fluids daily to irrigate the catheter.

Correct answer: C

Rationale: The most crucial instruction for a client with an indwelling urinary catheter post-bladder surgery is to keep the drainage bag positioned lower than the level of the bladder. This positioning prevents backflow of urine into the bladder, reducing the risk of infection. Choice A, avoiding coiling the tubing and keeping it free of kinks, is important to maintain proper flow but not as critical as ensuring the drainage bag is lower than the bladder. Choice B, cleansing the perineal area, is essential for overall hygiene but not directly related to catheter care instructions. Choice D, drinking fluids to irrigate the catheter, is not recommended as it may increase the risk of infection and should be guided by healthcare providers based on specific needs.

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