Nursing Elites

1. The client with chronic obstructive pulmonary disease (COPD) is being educated about lifestyle changes. Which statement by the client indicates a need for further teaching?

• A. I will reduce my salt intake.
• B. I will exercise for 30 minutes most days of the week.
• C. I will drink alcohol only on the weekends.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients with COPD should limit alcohol intake, not just to weekends, to effectively manage their condition. Excessive alcohol consumption can worsen respiratory symptoms and interfere with medications. Choices A, B, and D are all appropriate and beneficial for clients with COPD. Salt intake reduction helps in managing fluid retention and blood pressure. Regular exercise improves lung function and overall health. Monitoring blood pressure is crucial for individuals with COPD as hypertension is a common comorbidity.

2. A client with a terminal illness asks the nurse about what would happen if she arrived at the emergency department and had difficulty breathing, despite declining resuscitation in her living will. Which of the following responses should the nurse provide?

• A. We will determine who the durable power of attorney for health care form has designated.
• B. We will apply oxygen through a tube in your nose.
• C. We will ask if you have changed your mind.
• D. We will insert a breathing tube while we evaluate your condition.

Correct answer: B

Rationale: The correct response is to provide oxygen through a tube in the client's nose. Oxygen therapy can offer comfort and support breathing without being considered resuscitative. Therefore, this intervention aligns with the client's wish to decline resuscitation. Option A is not directly related to addressing the client's immediate breathing difficulty. Option C does not acknowledge the client's living will decision. Option D involves a more invasive procedure that may go against the client's wishes to decline resuscitation.

3. A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

• A. Ensure sterilization of non-disposable items with ethylene oxide
• B. Wrap monitoring cords with stockinette and secure them with non-latex tape
• C. Cleanse latex ports on IV tubing with chlorhexidine before administering medication
• D. Wear hypoallergenic latex gloves that are powder-free

Correct answer: B

Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.

4. Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?

• A. Risk for aspiration
• B. Impaired physical mobility
• C. Disturbed sensory perception
• D. Interrupted family processes

Correct answer: A

Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.

5. A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?

• A. People in middle adulthood often find satisfaction in nurturing and guiding young people.
• B. It's normal to feel this way; it will pass.
• C. You should focus on finding new activities to fill your time.
• D. Your children will always need you in some way.

Correct answer: A

Rationale: The correct response is A. Middle adulthood is a stage where individuals often experience generativity, finding fulfillment in guiding and nurturing others. By acknowledging this aspect, the nurse can help the client explore opportunities to engage in activities that provide a sense of purpose and satisfaction. Choice A validates the client's feelings and offers a constructive way to address them. Choices B, C, and D do not address the client's emotional need for purpose and may not encourage the client to seek meaningful ways to address their feelings of uselessness.

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