Nursing Elites

1. The client is diagnosed with pneumonia. Which intervention is most effective in promoting airway clearance?

• A. Administer bronchodilators as prescribed
• B. Encourage increased fluid intake
• C. Perform chest physiotherapy
• D. Provide humidified oxygen

Correct answer: B

Rationale: Encouraging increased fluid intake is the most effective intervention in promoting airway clearance for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making it easier for the client to clear the airways. Administering bronchodilators may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy may be beneficial but is not the first-line intervention for promoting airway clearance in pneumonia. Providing humidified oxygen can improve oxygenation but does not directly address airway clearance.

2. A client with a diagnosis of osteoporosis is prescribed alendronate (Fosamax). What is the most important instruction the nurse should provide?

• A. Take the medication in the morning on an empty stomach.
• B. Take the medication at bedtime.
• C. Remain upright for at least 30 minutes after taking the medication.
• D. Take the medication with a full glass of water.

Correct answer: D

Rationale: The most important instruction the nurse should provide to a client prescribed alendronate (Fosamax) for osteoporosis is to take the medication with a full glass of water. This is crucial to help prevent esophageal irritation. Option A is correct as alendronate should be taken in the morning on an empty stomach. Option C is incorrect because the client should remain upright for at least 30 minutes after taking the medication, not lie down. Option B is incorrect and a duplicate of Option A.

3. A client with chronic obstructive pulmonary disease (COPD) is using a metered-dose inhaler (MDI). What technique should the nurse emphasize?

• A. The importance of using a spacer
• B. How to synchronize breaths with inhaler activation
• C. Regular cleaning of the inhaler
• D. All of the above

Correct answer: D

Rationale: In managing COPD with a metered-dose inhaler (MDI), the nurse should emphasize all of the techniques mentioned. Using a spacer can help improve drug delivery and reduce the risk of oral thrush. Synchronizing breaths with inhaler activation ensures proper medication delivery to the lungs. Regular cleaning of the inhaler prevents blockages and ensures optimal functioning. Therefore, all these techniques are important for effective COPD management, making 'All of the above' the correct answer. Choices A, B, and C are all crucial components of proper MDI technique in COPD, so they are not individually sufficient without the others.

4. The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?

• A. Apply an ice pack
• B. Document the findings and monitor
• C. Notify the surgeon
• D. Clean the wound with sterile saline

Correct answer: C

Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.

5. An adult female client is admitted to the psychiatric unit with a diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement?

• A. Tell the client to keep her belongings because she will need them at discharge
• B. Ask the client if she has had any recent thoughts of harming herself
• C. Reassure the client that the antidepressant drugs are apparently effective
• D. Support the client by telling her what wonderful progress she is making

Correct answer: B

Rationale: In this scenario, the nurse should ask the client if she has had any recent thoughts of harming herself. Sudden mood improvements and behavioral changes, like giving away belongings, can be concerning signs of possible suicidal ideation. Assessing for suicidal thoughts is crucial to ensure the client's safety. Choice A is incorrect as it does not address the potential risk of harm or assess for suicidal ideation. Choice C is incorrect because simply reassuring the client about the effectiveness of antidepressants does not address the immediate concern of suicidal ideation. Choice D is incorrect as it focuses on praising progress without addressing the potential risk of harm the client may pose to herself.

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