Nursing Elites

1. The nurse is preparing a teaching plan for a client diagnosed with asthma. The primary purpose of the plan is to

• A. Prevent respiratory infections
• B. Prevent airway inflammation
• C. Maintain an open airway
• D. Avoid allergens that trigger attacks

Correct answer: D

Rationale: Avoiding allergens that trigger asthma attacks is crucial in managing the condition and preventing exacerbations. While preventing respiratory infections and maintaining an open airway are important aspects of asthma management, the primary focus of the teaching plan is to help the client identify and avoid allergens that could trigger asthma attacks. This proactive approach can significantly reduce the frequency and severity of asthma symptoms.

2. The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?

• A. Elevate the head of the bed to 15 degrees during feedings
• B. Aspirate gastric contents before administering medications
• C. Clamp the tube between feedings
• D. Flush the tube with water before and after feedings

Correct answer: D

Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.

3. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

• A. White blood cell count
• B. Hemoglobin
• C. Serum creatinine
• D. Culture for sensitive organisms

Correct answer: D

Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.

4. A male client with HIV on antiretroviral therapy complains of constant hunger and thirst while losing weight. What action should the nurse implement?

• A. Check the client's glucose level with a glucometer.
• B. Measure the client's weight accurately.
• C. Reassure the client that weight will stabilize as viral load decreases.
• D. Increase the dose of saquinavir.

Correct answer: A

Rationale: The correct action for the nurse to implement is to check the client's glucose level with a glucometer. Constant hunger and thirst along with weight loss can be indicative of hyperglycemia, a possible side effect of saquinavir. Monitoring the client's glucose levels is crucial in this situation. Measuring the client's weight accurately (Choice B) is important for monitoring purposes but does not address the immediate concern of hunger, thirst, and weight loss. Reassuring the client that weight will stabilize as viral load decreases (Choice C) is not appropriate in this scenario as the symptoms described need immediate attention. Increasing the dose of saquinavir (Choice D) without assessing the client's glucose level can worsen the hyperglycemia.

5. Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus?

• A. Maintaining a low-sugar diet
• B. Foot care
• C. Blood glucose monitoring
• D. Daily exercise

Correct answer: C

Rationale: Blood glucose monitoring is crucial for managing diabetes effectively. By monitoring blood sugar levels, individuals can understand how their lifestyle choices, medications, and diet affect their glucose levels. This information helps in making necessary adjustments to control blood sugar levels and prevent complications. While maintaining a low-sugar diet, foot care, and daily exercise are all important aspects of managing diabetes, blood glucose monitoring takes precedence as it provides real-time data for informed decision-making.

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