Nursing Elites

1. The nurse is caring for a client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD?

• A. Administering narcotics for pain relief
• B. Encouraging the client to increase fluid intake
• C. Applying oxygen therapy at a high flow rate
• D. Assisting the client with deep breathing exercises

Correct answer: C

Rationale: The correct answer is C: Applying oxygen therapy at a high flow rate. In clients with COPD, high levels of supplemental oxygen can suppress the hypoxic drive to breathe, leading to carbon dioxide retention and respiratory depression. Oxygen therapy must be administered cautiously to prevent worsening respiratory status. Administering narcotics for pain relief (Choice A) can be necessary but should be done judiciously. Encouraging fluid intake (Choice B) and assisting with deep breathing exercises (Choice D) are generally beneficial interventions for clients with COPD and should not require the same level of caution as high-flow oxygen therapy.

2. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?

• A. Ensure early ambulation
• B. Administer antibiotics as prescribed
• C. Maintain strict intake and output
• D. Monitor blood glucose levels

Correct answer: C

Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.

3. A client reports dizziness when standing up quickly. What advice should the nurse give?

• A. Encourage the client to drink more fluids.
• B. Change positions slowly to prevent dizziness.
• C. Report the symptom to the healthcare provider immediately.
• D. Limit physical activity to avoid triggering dizziness.

Correct answer: B

Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (Choice A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (Choice C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (Choice D) may not necessarily address the underlying cause of dizziness in this context.

4. The nurse is caring for a seated client experiencing a tonic-clonic seizure. Which actions should the nurse implement?

• A. Place a padded tongue depressor in the client's mouth
• B. Restrain the client and attempt to stop the seizure
• C. Begin CPR immediately
• D. Loosen restrictive clothing and ease the client to the floor

Correct answer: D

Rationale: During a tonic-clonic seizure, the nurse should loosen restrictive clothing to prevent injury and ease the client to the floor to ensure safety. Placing any object, such as a tongue depressor, in the client's mouth is contraindicated as it may cause harm. Restraint should not be used as it can lead to injury. Beginning CPR is not indicated during a seizure unless the client experiences cardiac arrest, which is a rare complication of seizures.

5. What breakfast selection indicates appropriate dietary management for osteoporosis?

• A. Pancakes with syrup and orange juice
• B. Bagel with jelly and skim milk
• C. Eggs with sausage and whole milk
• D. French toast with butter and syrup

Correct answer: B

Rationale: The correct answer is B. A bagel with jelly and skim milk is a calcium-rich and low-fat option that aligns with the dietary recommendations for managing osteoporosis. Osteoporosis is a condition characterized by weak and brittle bones, so it is essential to consume an adequate amount of calcium while avoiding excess fat intake. Choices A, C, and D are not ideal for osteoporosis management as they either lack sufficient calcium, contain high fat content, or both.

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