Nursing Elites

1. The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?

• A. To promote oxygenation by removing secretions.
• B. To reduce the amount of air trapped in the lungs.
• C. To increase the amount of carbon dioxide exhaled.
• D. To slow the respiratory rate and improve air exchange.

Correct answer: C

Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A) and reducing air trapping (B) can be associated benefits to some extent, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics. Slowing the respiratory rate (D) is not the primary purpose of pursed-lip breathing.

2. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

• A. That means you have derived the maximum benefit, and the heat can be removed.
• B. Your blood vessels are becoming dilated and removing the heat from the site.
• C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
• D. The body's receptors adapt over time as they are exposed to heat.

Correct answer: D

Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.

3. When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?

• A. Ask him to rate his pain on a scale of 1 to 10.
• B. Encourage him to wait until bedtime for the pill to help him sleep.
• C. Attend to an acutely ill client's needs first as the client is laughing.
• D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: The correct response is to ask the client to rate his pain on a scale of 1 to 10. This helps the nurse assess the intensity of the pain and determine the appropriate pain medication. Encouraging him to wait or attend to another client's needs first are incorrect because pain management should be addressed promptly. Instructing on deep breathing exercises may be helpful but is not the initial step in addressing acute pain.

4. What is the most effective way to implement a teaching plan?

• A. Teach the information that the learner wants to learn first.
• B. Streamline the teaching plan to include only essential information.
• C. Present to the learner all the necessary information to meet the objectives.
• D. Provide the learner with written material to review before teaching sessions.

Correct answer: A

Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.

5. The healthcare professional in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague’s assignment. Which action should the healthcare professional implement?

• A. Communicate the colleague’s actions to the unit charge nurse
• B. Send an email to facility administration reporting the action
• C. Write an anonymous complaint to a professional website
• D. Post a comment about the action on a staff discussion board

Correct answer: A

Rationale: Observing a colleague accessing a patient's EHR without a legitimate reason is a violation of HIPAA, which protects patient confidentiality. The appropriate action in this scenario is to communicate the colleague’s actions to the unit charge nurse immediately. The charge nurse can then address the issue internally and ensure that patient privacy is maintained. Reporting the incident through the appropriate channels within the healthcare facility is the most effective and professional way to handle such breaches of patient confidentiality. Choices B, C, and D are incorrect because they do not involve addressing the issue internally within the healthcare facility. Reporting such incidents internally is essential to ensure that patient privacy is protected, and the matter is handled appropriately by healthcare authorities.

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