Nursing Elites

1. The nurse is assessing a client who has been diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical finding is characteristic of this condition?

• A. Pursed-lip breathing
• B. Hyperresonance on percussion
• C. Bradycardia
• D. High-pitched inspiratory crackles

Correct answer: A

Rationale: Pursed-lip breathing is a characteristic finding in clients with COPD. It helps keep the airways open during exhalation, acting as a compensatory mechanism to prevent airway collapse, which is common in COPD. Hyperresonance on percussion is typically found in conditions like emphysema, which is a component of COPD but not characteristic of the overall disease. Bradycardia is not typical in COPD; instead, clients often exhibit tachycardia due to chronic hypoxemia. High-pitched inspiratory crackles are more commonly associated with conditions like pneumonia, not COPD.

2. A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.)

• A. Raisin bran muffins
• B. Bowl of oatmeal
• C. Cup of raspberries
• D. Scrambled eggs

Correct answer: A

Rationale: A high-fiber diet is beneficial for managing hemorrhoids as it helps maintain bowel regularity. Raisin bran muffins are a good choice for breakfast as they are high in fiber. Oatmeal is also a high-fiber option that aids digestion and prevents constipation. Raspberries are rich in fiber and contribute to a high-fiber diet. Scrambled eggs, on the other hand, are not high in fiber and do not provide the necessary fiber content needed for managing hemorrhoids.

3. The nurse is caring for a client with a history of seizure disorder who is receiving phenytoin (Dilantin). Which laboratory value is most important to monitor?

• A. Phenytoin level
• B. Sodium level
• C. Hemoglobin level
• D. White blood cell count

Correct answer: A

Rationale: Corrected Rationale: Monitoring the phenytoin level is crucial to ensure it is within the therapeutic range and to prevent toxicity. Monitoring sodium level is important in clients receiving lithium, not phenytoin. Hemoglobin level and white blood cell count are not directly related to phenytoin therapy monitoring.

4. The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow the rate of transfusion.
• B. Administer an antipyretic.
• C. Stop the transfusion immediately.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.

5. What is the function of the cervix in reproduction?

• A. Accepts and interprets signals of sexual stimuli
• B. Secretes mucus to facilitate sperm transport
• C. Serves as the site for union of ovum and sperm
• D. Receives the penis during intercourse

Correct answer: B

Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.

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