Nursing Elites

1. The nurse instructs a client to use an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?

• A. Instruct the client to inhale more deeply
• B. Remind the client to cough after using the spirometer
• C. Praise the client for correct usage
• D. Suggest increasing the frequency of spirometer use

Correct answer: B

Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.

2. A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?

• A. Prothrombin time (PT)
• B. International normalized ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Platelet count

Correct answer: C

Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.

3. 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.

4. A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?

• A. Encourage the client to increase physical activity.
• B. Encourage the client to take rest breaks during activities.
• C. Administer a stimulant medication to reduce fatigue.
• D. Advise the client to use energy conservation techniques.

Correct answer: D

Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.

5. A client with Alzheimer's disease is exhibiting signs of agitation and aggression. What is the nurse's priority intervention?

• A. Reassure the client and provide emotional support.
• B. Redirect the client to a quiet activity.
• C. Administer a PRN dose of lorazepam.
• D. Apply soft restraints as needed to prevent harm.

Correct answer: B

Rationale: The correct answer is to redirect the client to a quiet activity. This intervention helps reduce agitation and aggression in clients with Alzheimer's disease by providing a distraction and promoting a calming environment. Reassuring the client and providing emotional support (Choice A) can be beneficial but is not the priority in this situation. Administering a PRN dose of lorazepam (Choice C) should not be the first intervention due to the risk of adverse effects and should only be considered if other non-pharmacological interventions are ineffective. Applying restraints (Choice D) should be avoided unless absolutely necessary for the client's safety as it can lead to further distress and is not the initial priority intervention.

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