Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which of these actions should the nurse perform first?

• A. Administer oxygen therapy
• B. Encourage the client to perform deep breathing exercises
• C. Raise the head of the bed
• D. Check the client's oxygen saturation level

Correct answer: D

Rationale: The correct answer is to check the client's oxygen saturation level first. This action is crucial in assessing the severity of dyspnea and determining the necessity for oxygen therapy. Administering oxygen therapy without knowing the current oxygen saturation level can be inappropriate and potentially harmful. Encouraging deep breathing exercises and raising the head of the bed are important interventions, but assessing the oxygen saturation level takes precedence in managing dyspnea in a client with COPD.

2. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?

• A. Bleeding time
• B. Platelet count
• C. Activated PTT
• D. Clotting time

Correct answer: C

Rationale: Activated PTT is the correct lab value to monitor for clients on heparin therapy. Activated PTT (partial thromboplastin time) helps assess the effectiveness of heparin therapy by measuring the time it takes for blood to clot. Monitoring activated PTT ensures that the client is within the therapeutic range of heparin to prevent both clotting and bleeding complications. Bleeding time (Choice A) and platelet count (Choice B) are not specific indicators of heparin therapy effectiveness. Clotting time (Choice D) is not as sensitive as activated PTT in monitoring heparin therapy.

3. When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?

• A. An infant who has been identified to have botulism
• B. A toddler who ate a number of ibuprofen tablets
• C. A preschooler who swallowed powdered plant food
• D. A school-aged child who took a handful of vitamins

Correct answer: A

Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.

4. A nurse is reinforcing teaching with a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?

• A. Increase fluid intake by drinking bottled water.
• B. A salad bar is a healthy choice when dining out.
• C. Soft-boiled eggs are an appropriate source of protein.
• D. Eating at buffets is a good choice to increase caloric intake.

Correct answer: A

Rationale: Clients with neutropenia should avoid foods that may be contaminated to prevent infections. Increasing fluid intake is important to stay hydrated, but it's crucial to use safe sources like bottled water to reduce the risk of infection. Choices B, C, and D are not appropriate for a client with neutropenia. Salad bars may contain raw or unwashed produce, soft-boiled eggs may carry a risk of contamination, and buffets may have food items that are not recommended for someone with neutropenia.

5. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?

• A. Decreased urinary output
• B. Jugular vein distention
• C. Pleural effusion
• D. Bibasilar crackles

Correct answer: B

Rationale: In right-sided congestive heart failure, the nurse would anticipate finding jugular vein distention. This occurs due to increased venous pressure, leading to the distention of the jugular veins in the neck. Choices A, C, and D are incorrect. Decreased urinary output is not typically associated with right-sided heart failure; pleural effusion and bibasilar crackles are more commonly seen in conditions like left-sided heart failure.

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