Nursing Elites

1. A client diagnosed with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurses to instruct the client about self-care?

• A. Call the clinic if undesirable side effects of medications occur
• B. Avoid crowded enclosed areas to reduce pathogen exposure
• C. Increase the daily intake of oral fluids to liquefy secretions
• D. Teach anxiety reduction methods for feelings of suffocation

Correct answer: C

Rationale: Increasing the daily intake of oral fluids is crucial for clients with asthma and bronchitis as it helps to liquefy thickened mucus, making it easier to clear the airways and manage symptoms. This self-care measure can improve the client's ability to breathe more effectively. Choice A is not the most immediate concern when addressing thickened mucus and breathing difficulties. While avoiding crowded areas is beneficial to prevent respiratory infections, it is not directly related to managing thickened secretions. Teaching anxiety reduction methods is important for overall well-being, but it does not directly address the physiological issue of thickened mucus in the airways.

2. A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.)

• A. You will not need vascular access to perform PD.
• B. There is less restriction of protein and fluids.
• C. You have flexible scheduling for the exchanges.
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, as all the statements are accurate advantages of peritoneal dialysis (PD). Peritoneal dialysis does not require vascular access, offers less restriction on protein and fluids, and provides flexibility in scheduling for the exchanges. Choice A is correct because one of the advantages of PD is not needing vascular access, which is required in hemodialysis. Choice B is correct because PD allows for less dietary restriction compared to hemodialysis. Choice C is correct because PD allows for flexible scheduling of exchanges, providing more independence to the individual undergoing treatment.

3. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis?

• A. Frequent use of chewable and liquid antacids for indigestion
• B. Severe abdominal cramps and diarrhea after eating spicy foods
• C. Upper mid-abdominal gnawing and burning pain
• D. Marked weight loss and appetite over the last 3 to 4 months

Correct answer: C

Rationale: The correct answer is C: 'Upper mid-abdominal gnawing and burning pain.' This symptom is a classic presentation of peptic ulcer disease. Antacids (choice A) may provide relief but do not confirm the diagnosis. Severe abdominal cramps and diarrhea (choice B) are more suggestive of other conditions like irritable bowel syndrome. Weight loss and appetite changes (choice D) are non-specific and could be related to various health issues.

4. A client with a history of calcium phosphate urinary stones is being taught by a nurse. Which statements should the nurse include in this client’s dietary teaching? (Select all that apply.)

• A. Limit your intake of food high in animal protein.
• B. Read food labels to help minimize your sodium intake.
• C. A and B
• D. Reduce your intake of milk and other dairy products.

Correct answer: C

Rationale: For a client with a history of calcium phosphate urinary stones, it is essential to limit the intake of foods high in animal protein to prevent the formation of stones. Additionally, reducing sodium intake is crucial as high sodium levels can contribute to stone formation. Therefore, choices A and B are correct. Choice D, which suggests reducing intake of milk and other dairy products, is not specifically recommended for calcium phosphate stones. Clients with calcium phosphate stones should focus on limiting animal protein, sodium, and calcium intake. Choices A and B address these dietary modifications, making them the correct options for this client. Choices D, which is not directly related to calcium phosphate stones, is incorrect.

5. A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 ml over the past 24 hours with a central venous pressure of 15 mmHg. The nurse notes respiratory crackles and bounding central pulse. Vital signs: temperature 101.2 F (38.4 C), heart rate 96 beats/minute, respiration 24 breaths/minute, and blood pressure of 160/90 mmHg. Which intervention should the nurse implement first?

• A. Calculate total intake and output for the last 24 hours.
• B. Administer a PRN dose of acetaminophen.
• C. Decrease IV fluids to a keep vein open (KVO) rate.
• D. Review the last administration of IV pain medication.

Correct answer: C

Rationale: In this scenario, the client is showing signs of fluid volume excess, such as drowsiness, abdominal pain, headache, crackles in the lungs, bounding pulse, and elevated blood pressure. Decreasing the IV fluids to a keep vein open (KVO) rate is crucial to prevent further fluid overload. This intervention helps in balancing fluid intake and output to prevent complications associated with fluid volume excess. Calculating total intake and output (Choice A) may be necessary but not the immediate priority in managing fluid overload. Administering acetaminophen (Choice B) may help with managing the fever but does not address the underlying issue of fluid overload. Reviewing the last administration of IV pain medication (Choice D) is not the priority in this situation where fluid overload is a concern.

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