Nursing Elites

1. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce the occurrence of embolisms.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

2. The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?

• A. Coarse crackles in the lungs.
• B. Fever of 101.2°F (38.4°C).
• C. Productive cough with yellow sputum.
• D. Respiratory rate of 28 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.

3. A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which intervention should the nurse implement first?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen via nasal cannula.
• C. Encourage the client to cough and deep breathe.
• D. Position the client in high Fowler's position.

Correct answer: B

Rationale: Administering oxygen via nasal cannula (B) is the priority intervention for a client with COPD exacerbation to improve oxygenation. In COPD exacerbation, there is impaired gas exchange leading to hypoxemia, making oxygen therapy the initial priority. Administering bronchodilators (A) helps with bronchodilation but should come after ensuring adequate oxygenation. Encouraging coughing and deep breathing (C) and positioning the client in high Fowler's position (D) are also beneficial interventions, but the first step is to address the oxygenation needs of the client.

4. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?

• A. Ventrogluteal
• B. Outer upper quadrant of the buttock
• C. Two inches below the acromion process
• D. Vastus lateralis

Correct answer: A

Rationale: The ventrogluteal site is the preferred location for administering large volume IM injections to avoid nerve injury. This site is situated away from major nerves and blood vessels, reducing the risk of complications associated with injecting into other areas. The ventrogluteal site allows for deep muscle penetration and is recommended for injections over 2 mL in volume to ensure proper dispersion and absorption of the medication. Choices B, C, and D are incorrect because the outer upper quadrant of the buttock is not the recommended site for large volume injections, two inches below the acromion process is a location for a deltoid injection, and the vastus lateralis is typically used for smaller volume injections.

5. A client with a diagnosis of coronary artery disease is receiving atorvastatin (Lipitor). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

• A. Complete blood count (CBC)
• B. Serum potassium level
• C. Liver function tests (LFTs)
• D. Serum cholesterol level

Correct answer: C

Rationale: To evaluate the effectiveness of atorvastatin (Lipitor), the nurse should monitor liver function tests (LFTs) (C) because this medication can impact liver function. Complete blood count (CBC) (A), serum potassium level (B), and serum cholesterol level (D) are not directly indicative of the medication's effectiveness in managing coronary artery disease.

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