Nursing Elites

1. The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?

• A. Assess the client's oxygen saturation level
• B. Teach the client pursed-lip breathing techniques
• C. Determine the client's history of lung disease
• D. Obtain an arterial blood gas sample

Correct answer: A

Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.

2. The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central venous catheter. Which assessment finding indicates a complication related to the TPN?

• A. Blood glucose level of 180 mg/dl
• B. Serum potassium level of 4.0 mEq/L
• C. Weight gain of 2 pounds in 24 hours
• D. White blood cell count of 7000/mm3

Correct answer: C

Rationale: A weight gain of 2 pounds in 24 hours is concerning as it indicates fluid retention, a potential complication of TPN leading to fluid overload. Elevated blood glucose levels (Choice A) are expected in TPN, serum potassium levels (Choice B) are within the normal range, and a white blood cell count (Choice D) of 7000/mm3 is also normal. Therefore, the correct answer is C, as it suggests a complication related to TPN.

3. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?

• A. Remind the client that it is also important to schedule an annual mammogram
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure
• C. Encourage the client to perform BSE 2 to 3 days after the menstrual period ends
• D. Instruct the client to continue with her regular monthly exams as she is doing

Correct answer: C

Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination. Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE. Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review. Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.

4. When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr?

• A. 42
• B. 50
• C. 60
• D. 70

Correct answer: A

Rationale: To calculate the infusion rate, we first need to determine the frequency of contractions per hour. If contractions are occurring every 2 to 3 minutes, this corresponds to 20 to 30 contractions in an hour (60 minutes). The average is 25 contractions in an hour. The pump should be infusing 1 ml for each contraction, so the infusion rate should be 25 ml/hr. Therefore, the correct answer is 42 ml/hr. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

5. A nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in this client's plan of care?

• A. Maintain the client on bed rest
• B. Apply warm, moist compresses to the legs
• C. Encourage early ambulation
• D. Massage the legs daily

Correct answer: C

Rationale: The correct intervention for a client at risk for developing deep vein thrombosis (DVT) is to encourage early ambulation. Early ambulation helps prevent DVT by promoting circulation, reducing stasis, and preventing blood clot formation. Maintaining the client on bed rest (Choice A) would increase the risk of DVT due to decreased mobility. Applying warm, moist compresses to the legs (Choice B) can be beneficial for other conditions but does not directly prevent DVT. Massaging the legs daily (Choice D) can dislodge a blood clot, leading to serious complications in a client at risk for DVT.

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