Nursing Elites

1. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?

• A. Use oxygen at the highest flow rate tolerated.
• B. Do not smoke while using oxygen.
• C. Avoid wearing the oxygen during physical activity.
• D. Store oxygen tanks in a cool, dark place.

Correct answer: B

Rationale: The most important instruction the nurse should provide to a client with COPD receiving home oxygen therapy is not to smoke while using oxygen. Smoking near oxygen can cause a fire or explosion due to the flammable nature of oxygen. Choice A is incorrect because using oxygen at the highest flow rate tolerated without medical supervision can be harmful. Choice C is the correct answer as wearing oxygen during physical activity can increase the risk of oxygen combustion. Choice D is not the most important instruction; while storing oxygen tanks properly is essential, the immediate safety concern is the risk of fire due to smoking near oxygen.

2. What intervention has the highest priority for a client with a fourth-degree midline laceration following the vaginal delivery of an 8-pound 10-ounce infant?

• A. Administer a prescribed stool softener
• B. Administer prescribed PRN sleep medications
• C. Encourage breastfeeding to promote uterine involution
• D. Encourage the use of prescribed analgesic perineal sprays

Correct answer: A

Rationale: Administering a prescribed stool softener is the highest priority intervention for a client with a fourth-degree midline laceration to prevent straining during bowel movements, which could potentially harm the healing laceration. Stool softeners help in maintaining soft stools, reducing the risk of injury to the suture line. Administering PRN sleep medications, encouraging breastfeeding, or promoting the use of analgesic perineal sprays are important aspects of care but are not the priority in this situation. Stool softeners play a crucial role in preventing complications and promoting healing in such cases, making it the most urgent intervention.

3. While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?

• A. Endotracheal cuff pressure greater than 25 cm H2O.
• B. Decreased lung compliance during ventilation.
• C. Bilateral crackles with increased secretions.
• D. Restless client who is biting the endotracheal tube.

Correct answer: D

Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.

4. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?

• A. Take the medication with food.
• B. Expect to see improvement within 24 hours.
• C. Avoid drinking grapefruit juice.
• D. Report any thoughts of self-harm immediately.

Correct answer: D

Rationale: The correct answer is D: 'Report any thoughts of self-harm immediately.' Clients prescribed SSRIs should be educated to report any thoughts of self-harm promptly, as these medications can initially increase suicidal ideation. Choice A is incorrect because SSRIs are usually taken on an empty stomach. Choice B is incorrect as it takes several weeks for SSRIs to reach their full effectiveness. Choice C is irrelevant to SSRI therapy.

5. A client with a history of asthma is experiencing wheezing and shortness of breath. What is the priority nursing intervention?

• A. Administer a bronchodilator as prescribed
• B. Encourage the client to drink fluids
• C. Place the client in an upright position
• D. Assess the client's peak flow rate

Correct answer: A

Rationale: Administering a bronchodilator as prescribed is the priority nursing intervention for a client experiencing wheezing and shortness of breath due to asthma. Bronchodilators help relieve bronchoconstriction, allowing better airflow and improving breathing. Encouraging the client to drink fluids may be beneficial in certain situations, but it is not the priority when the client is in respiratory distress. Placing the client in an upright position, not supine, can facilitate easier breathing by allowing the chest to expand fully. While assessing the client's peak flow rate is important in asthma management, in this acute situation, the priority is to provide immediate relief by administering the bronchodilator.

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