Nursing Elites

1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?

• A. Decrease the oxygen flow rate
• B. Increase the oxygen flow rate
• C. Encourage the client to cough and deep breathe
• D. Monitor the client's oxygen saturation level

Correct answer: A

Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.

2. A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?

• A. Use a 1-inch needle
• B. Select a large muscle for the injection
• C. Aspirate for blood return before injecting
• D. Massage the injection site

Correct answer: C

Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.

3. A client diagnosed with tuberculosis (TB) is placed on drug therapy with rifampin (Rifadin). The client should be instructed to report which effect(s) of the medication to the healthcare provider?

• A. Reddish-orange discoloration of body fluids
• B. Bloody or blood-tinged urine
• C. Blurring of vision
• D. Weight gain of more than 2 pounds in a week

Correct answer: A

Rationale: The correct answer is A. Rifampin (Rifadin) commonly causes a reddish-orange discoloration of body fluids, including urine, sweat, saliva, and tears. This is a harmless side effect but should be reported to the healthcare provider for monitoring. Choices B, C, and D are not typically associated with rifampin therapy. Bloody or blood-tinged urine may indicate other issues such as urinary tract infection or kidney problems, blurring of vision may suggest eye problems, and significant weight gain could be related to various health conditions unrelated to rifampin.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?

• A. Increase the oxygen flow rate
• B. Instruct the client to breathe deeply and cough
• C. Check the client's oxygen saturation level
• D. Place the client in a high-Fowler's position

Correct answer: C

Rationale: The correct action for the nurse to take first when a client with COPD reports difficulty breathing while receiving oxygen is to check the client's oxygen saturation level. This helps in determining the adequacy of oxygenation and identifying the cause of the breathing difficulty. Increasing the oxygen flow rate (Choice A) may not be appropriate without knowing the current oxygen saturation level. Instructing the client to breathe deeply and cough (Choice B) may not address the immediate need for oxygen assessment. Placing the client in a high-Fowler's position (Choice D) can help with breathing but should come after ensuring proper oxygenation.

5. A nurse is assessing the learning needs of a client who is diagnosed with Addison's disease. Which statement indicates that the client needs further teaching?

• A. I should take my medications daily to replace necessary hormones
• B. I need to eat a diet high in protein and carbohydrates
• C. I should avoid drinking fluids with caffeine
• D. I should notify my healthcare provider if I start feeling dizzy

Correct answer: B

Rationale: The correct answer is B. A diet high in protein and carbohydrates is not specifically required for Addison's disease. The focus should be on maintaining a balanced diet that is rich in fruits, vegetables, whole grains, and adequate protein sources. Choice A is correct as adherence to medication therapy is crucial in managing Addison's disease. Choice C is correct as caffeine can exacerbate symptoms of Addison's disease. Choice D is correct as dizziness can be a sign of adrenal crisis in Addison's disease, and prompt notification of healthcare providers is essential.

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