Nursing Elites

1. A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

• A. Confusion
• B. Weakness
• C. Increased intracranial pressure
• D. Increased urinary output

Correct answer: B

Rationale: In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.

2. A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?

• A. The student should use his quick-relief inhaler.
• B. The student's asthma is not well controlled.
• C. The student's peak flow is 50% to 80% of his best peak flow.
• D. The student needs to go to the hospital

Correct answer: D

Rationale: In an asthma action plan, the yellow zone indicates caution and signals a need to monitor symptoms closely. When a student is in the yellow zone, the appropriate action is to follow the prescribed steps, which typically include using a quick-relief inhaler and closely monitoring peak flow. Going to the hospital is usually reserved for severe asthma exacerbations in the red zone. Therefore, the information that the student needs to go to the hospital is not typically appropriate when the student is in the yellow zone.

3. When teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition, what information should be included? (Select all that apply)

• A. Avoid drinking fluids just before and during meals.
• B. Rest before meals if experiencing dyspnea.
• C. Have about six small meals a day.
• D. Eat high-fiber foods to promote gastric emptying.

Correct answer: D

Rationale: When educating a client with COPD about nutrition, it is important to consider factors that can impact breathing and digestion. Avoiding drinking fluids just before and during meals can help prevent bloating, which may impede breathing. Resting before meals if experiencing dyspnea can aid in reducing respiratory effort during eating. Having about six small meals a day can help prevent overeating and decrease the feeling of fullness, promoting easier breathing. However, it is crucial to be cautious with high-fiber foods as they can produce gas, leading to abdominal bloating and increased shortness of breath. Clients with COPD should focus on increasing calorie and protein intake to prevent malnourishment. It is advisable not to increase carbohydrate intake as this can elevate carbon dioxide production and exacerbate breathing difficulties.

4. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?

• A. Encourage the client to walk for 5 minutes each hour.
• B. Refer the client for smoking cessation classes.
• C. Teach the client about factor V Leiden testing.
• D. Explain to the client that sometimes no cause for the disease is found.

Correct answer: C

Rationale: The most appropriate action for the nurse in this scenario is to teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including pulmonary embolism (PE). In a case where a client has no known risk factors for PE, testing for this genetic disorder is crucial to determine if it is a contributing factor. Encouraging the client to walk or referring them to smoking cessation classes, while beneficial for overall health, are not directly relevant to the development of a PE in this specific case. While it is true that sometimes no cause for a disease is found, prematurely assuming this without appropriate investigations may lead to missed opportunities for preventive measures or treatments.

5. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What action should the nurse anticipate?

• A. Decrease the heparin rate.
• B. Increase the heparin rate.
• C. No change to the heparin rate.
• D. Stop the heparin; start warfarin (Coumadin).

Correct answer: B

Rationale: For clients on heparin therapy, a PTT value of 1.5 to 2.5 times the normal range is required to ensure therapeutic anticoagulation. The normal PTT range is 25 to 35 seconds. In this case, the client's PTT of 25 seconds falls below the therapeutic range, indicating that the heparin dose is insufficient. Therefore, the nurse should anticipate increasing the heparin rate to achieve the desired therapeutic effect.

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