Nursing Elites

1. The nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which statement by the client indicates a need for further teaching?

• A. I will use my albuterol inhaler before exercising.
• B. I will avoid secondhand smoke.
• C. I will get a flu shot every year.
• D. I will limit my fluid intake to 2 liters per day.

Correct answer: A

Rationale: Using an albuterol inhaler before exercising is appropriate for clients with COPD to prevent exercise-induced bronchospasm.

2. A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?

• A. Elevate the affected leg on a pillow.
• B. Apply a warm compress to the affected leg.
• C. Perform passive range-of-motion exercises on the affected leg.
• D. Encourage the client to ambulate frequently.

Correct answer: A

Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.

3. A client with hyperthyroidism is receiving radioactive iodine therapy. Which statement by the client indicates a need for further teaching?

• A. I should avoid close contact with pregnant women and children for a few days.
• B. I may experience dry mouth and taste changes for a few days.
• C. I may experience some neck swelling.
• D. I should expect to have no side effects.

Correct answer: D

Rationale: The correct answer is 'D.' The client stating 'I should expect to have no side effects' indicates a need for further teaching as it is incorrect. With radioactive iodine therapy, side effects like dry mouth, taste changes, and neck swelling are common. Choices A and B are correct statements; the client should avoid close contact with pregnant women and children due to radiation exposure, and dry mouth and taste changes are common side effects. Choice C is also correct, making D the correct answer.

4. The nurse is assessing a client with a suspected deep vein thrombosis (DVT). Which finding supports this diagnosis?

• A. Positive Homan's sign.
• B. Unilateral leg swelling.
• C. Bilateral calf pain.
• D. Redness and warmth in the affected leg.

Correct answer: D

Rationale: The correct answer is D: Redness and warmth in the affected leg. These are classic signs of deep vein thrombosis (DVT) and support the diagnosis. Choice A, Positive Homan's sign, is an outdated and unreliable test for DVT, so it is not the best choice. Choice B, Unilateral leg swelling, can be seen in DVT but is less specific compared to redness and warmth. Choice C, Bilateral calf pain, is not a typical finding in DVT, as the pain in DVT is usually unilateral.

5. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory result requires immediate intervention?

• A. Blood glucose of 250 mg/dL.
• B. Serum potassium of 3.5 mEq/L.
• C. Serum sodium of 135 mEq/L.
• D. Arterial blood pH of 7.30.

Correct answer: D

Rationale: An arterial blood pH of 7.30 indicates the client is in acidosis, which is a life-threatening condition in DKA. Immediate intervention is required to correct the acidosis and prevent further complications such as organ failure or coma. Blood glucose of 250 mg/dL is elevated but not an immediate threat to life in comparison to acidosis. Serum potassium of 3.5 mEq/L and serum sodium of 135 mEq/L are within normal ranges and do not warrant immediate intervention in the context of DKA.

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