Nursing Elites

1. A client is admitted with a diagnosis of pneumonia. Which intervention should the nurse implement to promote airway clearance?

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

Correct answer: B

Rationale: Encouraging increased fluid intake is the most appropriate intervention to promote airway clearance in a client with pneumonia. Adequate hydration helps to thin respiratory secretions, making it easier for the client to cough up and clear the airways. Administering bronchodilators (Choice A) may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy (Choice C) can be beneficial in certain cases but may not be the initial intervention for promoting airway clearance. Providing humidified oxygen (Choice D) can help improve oxygenation but does not specifically target airway clearance in pneumonia.

2. The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

• A. Increase sodium intake.
• B. Engage in regular physical activity.
• C. Avoid foods high in fat.
• D. Limit fluid intake to 1 liter per day.

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.

3. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?

• A. Inform the UAP that suction is available at the bedside.
• B. Instruct the UAP to notify the nurse if the client chokes.
• C. Observe the UAP's ability to implement precautions during feeding.
• D. Ask the UAP about previous experience in performing this skill.

Correct answer: C

Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.

4. A client with type 1 diabetes mellitus is learning to administer insulin. What is the best site for the nurse to recommend for insulin injection?

• A. Abdomen
• B. Thigh
• C. Upper arm
• D. Buttock

Correct answer: A

Rationale: The correct answer is the abdomen. The abdomen is the recommended site for insulin injection due to its faster absorption rate compared to other sites. Insulin injected into the abdomen is absorbed more quickly, leading to better glycemic control. The thigh and upper arm are also common sites for insulin injection, but they have slower absorption rates than the abdomen. The buttock is not a preferred site for insulin injection due to inconsistent absorption and potential risk of injecting into muscle instead of fatty tissue.

5. A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?

• A. It helps reduce the production of intestinal gases.
• B. It ensures clearer imaging by emptying the stomach.
• C. It prevents the risk of aspiration during the procedure.
• D. It is a standard procedure for all surgical interventions.

Correct answer: B

Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.

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