Nursing Elites

1. A client is admitted for COPD. Which finding would require the nurse's immediate attention?

• A. Nausea and vomiting
• B. Restlessness and confusion
• C. Low-grade fever and cough
• D. Irritating cough and liquefied sputum

Correct answer: B

Rationale: Restlessness and confusion are signs of hypoxia and hypercapnia in a client with COPD, indicating that the client's condition may be deteriorating rapidly. Immediate attention is necessary to prevent further complications. Nausea and vomiting (Choice A) may be related to various factors but do not directly indicate respiratory distress. Low-grade fever and cough (Choice C) are common in COPD and may not require immediate intervention. Irritating cough and liquefied sputum (Choice D) are typical symptoms of COPD exacerbation but do not signal an immediate need for attention as restlessness and confusion.

2. The client with atrial fibrillation is being taught about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid?

• A. Large indoor gatherings
• B. Exposure to sunlight
• C. Active physical exercise
• D. Foods rich in vitamin K

Correct answer: D

Rationale: The correct answer is D: Foods rich in vitamin K. Foods rich in vitamin K can interfere with the effectiveness of Coumadin (warfarin) by promoting blood clotting. It is crucial for clients on this medication to maintain a consistent intake of vitamin K and avoid sudden dietary changes. Choices A, B, and C are incorrect as they are not directly related to the interaction of Coumadin (warfarin) with vitamin K. Large indoor gatherings, exposure to sunlight, and active physical exercise do not have a significant impact on the effectiveness of Coumadin (warfarin) in comparison to the interaction with foods rich in vitamin K.

3. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to:

• A. Administer pain medication
• B. Suction excessive tracheobronchial secretions
• C. Assist the client to turn, deep breathe, and cough
• D. Monitor oxygen saturation

Correct answer: B

Rationale: After a segmental lung resection, the priority nursing action should be to suction excessive tracheobronchial secretions. This helps in preventing airway obstruction from secretions, ensuring the patency of the airway and optimizing respiratory function. Administering pain medication can be important but addressing airway clearance takes precedence. Assisting the client to turn, deep breathe, and cough is essential for respiratory hygiene but not the first action immediately post-op. Monitoring oxygen saturation is crucial, but ensuring airway clearance is the priority to prevent complications.

4. The appropriate order of steps in active management of the third stage of labor includes:

• A. Cord clamping and cutting, controlled cord traction, ergometrine administration, and inspection to ensure the placenta is intact.
• B. Intravenous oxytocin, cord clamping and cutting, and fundal massage.
• C. Intramuscular injection of oxytocin, controlled cord traction with counter traction to the uterus, and uterine massage.
• D. Controlled cord traction, fundal massage, and oxytocin.

Correct answer: C

Rationale: The correct sequence of steps in active management of the third stage of labor includes intramuscular injection of oxytocin to prevent postpartum hemorrhage, controlled cord traction with counter traction to the uterus to facilitate placental delivery, and uterine massage to aid in uterine contraction and prevent excessive bleeding. Choice A is incorrect because ergometrine administration is not routinely recommended in active management. Choice B is incorrect as intravenous oxytocin is not the preferred route of administration. Choice D is incorrect as the order of steps is not accurate.

5. A 6-month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to

• A. Gently rub the skin with a cotton swab to relieve itching
• B. Place the favorite books and push-pull toys in the crib
• C. Check every few hours for the next day or 2 for swelling in the baby's feet
• D. Turn the baby with the abduction stabilizer bar every 2 hours

Correct answer: C

Rationale: The correct answer is to check every few hours for the next day or 2 for swelling in the baby's feet. Swelling in the baby's feet could indicate compromised circulation due to the cast, and frequent checks are necessary to ensure that there are no complications. Choices A, B, and D are incorrect because rubbing the skin with a cotton swab, placing favorite items in the crib, and turning the baby with the abduction stabilizer bar do not address the potential issue of compromised circulation and swelling in the baby's feet.

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