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. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?

• A. Temperature of 100.8°F
• B. A pulse rate of 150 beats per minute
• C. A respiratory rate of 10 breaths per minute
• D. A blood pressure of 180/110

Correct answer: C

Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.

3. What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?

• A. Filtration
• B. Diffusion
• C. Osmosis
• D. Active transport

Correct answer: C

Rationale: The correct answer is C: Osmosis. Osmosis is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space to maintain cellular balance. In osmosis, water moves across a semi-permeable membrane from an area of low solute concentration (hypotonic) to an area of high solute concentration (hypertonic). This process helps regulate the water content inside cells. Choices A, B, and D are incorrect. Filtration involves the movement of solutes and solvents through a membrane due to a pressure difference, diffusion is the movement of solutes from an area of high concentration to low concentration, and active transport requires energy to move substances against their concentration gradient.

4. When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?

• A. Use sterile technique for catheter care
• B. Ensure the catheter bag is below the level of the bladder
• C. Provide perineal care daily
• D. Change the catheter only when necessary

Correct answer: B

Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.

5. After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement?

• A. Instruct the client to take deep breaths.
• B. Place a wedge under the client's hip.
• C. Place the client in the Trendelenburg position.
• D. Remove the client's legs from the stirrups.

Correct answer: B

Rationale: Placing a wedge under the client's hip is the correct action in this scenario. This helps relieve the pressure on the vena cava, which can become compressed in the lithotomy position during pregnancy, improving circulation and reducing symptoms like dizziness and pallor. Instructing the client to take deep breaths (Choice A) may not address the underlying cause of the symptoms. Placing the client in the Trendelenburg position (Choice C) would worsen the situation by further compressing the vena cava. Removing the client's legs from the stirrups (Choice D) may provide temporary relief but does not address the root cause of the issue.

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