Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?

• A. I will keep my oxygen tank upright at all times.
• B. I will not use petroleum jelly to keep my nose from drying out.
• C. I will not smoke or allow others to smoke around me.
• D. I will call my doctor if I have difficulty breathing.

Correct answer: B

Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy due to the risk of fire. The client should avoid using petroleum-based products around oxygen equipment. Choices A, C, and D are all appropriate statements for a client with COPD receiving home oxygen therapy. Keeping the oxygen tank upright ensures proper oxygen flow, avoiding smoking or exposure to smoke helps prevent respiratory aggravation, and knowing to seek medical help promptly for breathing difficulties is essential for managing COPD effectively.

2. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

• A. Fat
• B. Fluid
• C. Flatus
• D. Hernias

Correct answer: D

Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.

3. A healthcare provider is assessing a client's ability to balance. Which of the following actions is appropriate when the healthcare provider conducts a Romberg test?

• A. Ask the client to extend their arms in front of their body.
• B. Ask the client to walk in a straight line heel to toe.
• C. Have the client stand with their feet together.
• D. Have the client place their hands on their hips.

Correct answer: C

Rationale: The Romberg test is a neurological test that assesses proprioception and balance. To perform this test, the client is asked to stand with their feet together and arms at their sides while closing their eyes. By removing visual input, the test challenges the vestibular and proprioceptive systems. Choices A, B, and D are incorrect because they do not align with the proper procedure for conducting the Romberg test. Extending arms in front, walking heel to toe, or placing hands on hips are not part of the Romberg test protocol and may introduce variables that could affect the assessment of balance.

4. A healthcare professional is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the healthcare professional expect?

• A. Decreased calcium
• B. Elevated potassium
• C. Increased sodium
• D. Low hemoglobin

Correct answer: A

Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (Choice B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (Choice C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (Choice D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.

5. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

• A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
• B. Pinch the skin on the back of the hand and observe for elasticity
• C. Assess the skin turgor on the abdomen by pinching the skin
• D. Check the skin turgor by pressing on the forearm and observing the rebound

Correct answer: A

Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.

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