Nursing Elites

1. A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia?

• A. Encourage mobilization and ambulation
• B. Encourage energy conservation with complete bed rest
• C. Provide humidified oxygen via nasal cannula
• D. Restrict oral (PO) and intravenous fluids

Correct answer: A

Rationale: The correct intervention to prevent complications associated with pneumonia is to encourage mobilization and ambulation. These activities help prevent complications such as atelectasis by promoting lung expansion. Encouraging energy conservation with complete bed rest (Choice B) is not ideal as it can lead to complications like muscle weakness and decreased lung expansion. Providing humidified oxygen via nasal cannula (Choice C) is important in pneumonia treatment but does not directly prevent complications associated with pneumonia itself. Restricting oral (PO) and intravenous fluids (Choice D) is not recommended as adequate hydration is crucial for pneumonia patients to maintain respiratory function and overall health.

2. How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?

• A. Abnormal skin color changes in a client with dark skin cannot be determined
• B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
• C. The lips and mucus membranes of a client with dark skin are dusky in color
• D. Cyanosis in a client with dark skin is seen in the sclera

Correct answer: C

Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.

3. A client with diabetes mellitus is scheduled for surgery. What is the most important preoperative instruction the nurse should provide?

• A. Take your insulin as usual
• B. Do not eat or drink after midnight
• C. Monitor your blood glucose closely
• D. Bring your glucose meter to the hospital

Correct answer: B

Rationale: The most important preoperative instruction for a client with diabetes mellitus scheduled for surgery is to instruct them not to eat or drink after midnight. This instruction is crucial to maintain NPO (nothing by mouth) status before surgery, reducing the risk of aspiration during anesthesia. While taking insulin as usual (Choice A) is important, doses can be adjusted by the healthcare team. Monitoring blood glucose closely (Choice C) is essential but not as critical preoperatively. Bringing a glucose meter to the hospital (Choice D) can be helpful but is not as vital as maintaining NPO status.

4. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed
• B. Perform chest physiotherapy
• C. Encourage increased fluid intake
• D. Provide humidified oxygen

Correct answer: C

Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

5. The nurse is assessing a newborn and notes that the infant has a yellowish tint to the skin. What should the nurse do next?

• A. Reassure the parents that this is normal
• B. Monitor the infant's bilirubin levels
• C. Increase the frequency of feedings
• D. Administer phototherapy

Correct answer: B

Rationale: When a newborn presents with a yellowish tint to the skin, it can indicate jaundice, which is caused by elevated bilirubin levels. Monitoring the infant's bilirubin levels is crucial to assess the severity of jaundice and determine the need for further intervention. Reassuring the parents without proper assessment could lead to delayed treatment if jaundice is present. Increasing the frequency of feedings may not address the underlying cause of jaundice. Administering phototherapy is a treatment option that should be based on bilirubin level assessment and healthcare provider's recommendation.

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