Nursing Elites

1. What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?

• A. Increase intake of high-calcium foods in your diet
• B. Wear a supportive bra during the day and at night
• C. Take over-the-counter pain relievers
• D. Perform regular breast massage

Correct answer: B

Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.

2. A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?

• A. Notify the healthcare provider of the client's distress.
• B. Auscultate the client's lung sounds and oxygen saturation.
• C. Determine if the client is experiencing anxiety.
• D. Assess the oxygen delivery system.

Correct answer: B

Rationale: The correct action for the nurse to implement first is to auscultate the client's lung sounds and oxygen saturation. This helps in assessing the respiratory status of the client, which is crucial in managing COPD and emphysema exacerbations. Checking for any abnormalities in lung sounds and monitoring oxygen saturation levels can provide important information for immediate intervention. Option A is not the first action to take in this situation as directly assessing the client's respiratory status is more immediate. Option C, determining if the client is experiencing anxiety, is important but should come after assessing the physical respiratory status. Option D, assessing the oxygen delivery system, is also essential but should follow the direct assessment of the client's respiratory status.

3. The nurse is providing discharge teaching to a client with newly diagnosed hypertension. Which lifestyle modification should the nurse emphasize to the client?

• A. Increase sodium intake to improve fluid balance
• B. Engage in regular physical activity
• C. Increase caffeine intake to improve energy
• D. Reduce potassium intake to lower blood pressure

Correct answer: B

Rationale: Engaging in regular physical activity is a crucial lifestyle modification for managing hypertension. Regular exercise helps improve cardiovascular health, lower blood pressure, and contribute to overall well-being. Choices A, C, and D are incorrect. Increasing sodium intake is not recommended for hypertension as it can worsen fluid retention and elevate blood pressure. Increasing caffeine intake is also not advised as it may lead to increased heart rate and blood pressure. Reducing potassium intake is not beneficial as potassium is essential for maintaining healthy blood pressure levels.

4. A client presents to the emergency department with a severe exacerbation of asthma. The nurse notes that the client is using accessory muscles to breathe and has an oxygen saturation of 86%. Which intervention should the nurse implement first?

• A. Place the client in a high-Fowler's position
• B. Obtain a peak flow reading
• C. Administer a bronchodilator
• D. Administer oxygen therapy

Correct answer: D

Rationale: The first priority in an acute asthma exacerbation is to administer oxygen to improve the client's oxygen saturation. In this scenario, the client has a low oxygen saturation level of 86%, indicating hypoxemia, which can be life-threatening. Administering oxygen therapy will help improve oxygenation and support vital organ function. Once the oxygen levels are stabilized, further interventions such as bronchodilators can be implemented. Placing the client in a high-Fowler's position may also be beneficial, but ensuring adequate oxygenation takes precedence in this critical situation. Obtaining a peak flow reading is important for asthma management but is not the first intervention needed in a client with severe hypoxemia.

5. A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?

• A. Taking a client's blood pressure
• B. Providing oral hygiene for a client
• C. Assessing a client's pain level
• D. Assisting a client with ambulation

Correct answer: C

Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.

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