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. Based on the documentation in the medical record, which action should the nurse implement next?

• A. Administer the rubella vaccine subcutaneously
• B. Observe the mother breastfeeding her infant
• C. Call the nursery for the infant's blood type result
• D. Administer Vicodin one tablet for pain

Correct answer: B

Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.

3. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?

• A. Administer bronchodilator therapy as prescribed
• B. Encourage deep breathing and coughing exercises
• C. Position the client in a high-Fowler's position
• D. Increase the oxygen flow rate

Correct answer: C

Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing in COPD patients. While administering bronchodilator therapy as prescribed (Choice A) is important, it is not the priority in this scenario. Encouraging deep breathing and coughing exercises (Choice B) can be beneficial but do not take precedence over positioning for improved respiratory function. Increasing the oxygen flow rate (Choice D) can be considered after the initial positioning to relieve respiratory distress, making it a later intervention.

4. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

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

Correct answer: C

Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

5. The client is being educated by the nurse about the side effects of prednisone. Which side effect should the client be instructed to report immediately?

• A. Weight gain.
• B. Increased appetite.
• C. Hyperglycemia.
• D. Fever or sore throat.

Correct answer: D

Rationale: The correct answer is D: Fever or sore throat. These symptoms should be reported immediately as they could indicate an infection, which can be serious in clients taking prednisone due to its immunosuppressive effects. Choices A and B are common side effects of prednisone but are not typically considered urgent. Choice C, hyperglycemia, is a known side effect of prednisone but is not an immediate concern compared to the potential of an infection signaled by fever or sore throat.

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