Nursing Elites

1. A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?

• A. Notify the healthcare provider of the client's distress.
• B. Auscultate the client's lung sounds and oxygen saturation.
• C. Determine if the client is experiencing anxiety.
• D. Assess the oxygen delivery system.

Correct answer: B

Rationale: The correct action for the nurse to implement first is to auscultate the client's lung sounds and oxygen saturation. This helps in assessing the respiratory status of the client, which is crucial in managing COPD and emphysema exacerbations. Checking for any abnormalities in lung sounds and monitoring oxygen saturation levels can provide important information for immediate intervention. Option A is not the first action to take in this situation as directly assessing the client's respiratory status is more immediate. Option C, determining if the client is experiencing anxiety, is important but should come after assessing the physical respiratory status. Option D, assessing the oxygen delivery system, is also essential but should follow the direct assessment of the client's respiratory status.

2. An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information?

• A. His daughter's observations suggest the client is depressed
• B. His compulsiveness about food may indicate new cognitive decline
• C. Obsessiveness with food is common in diabetic clients
• D. If the client was compulsive about food when he was younger, the aging process can magnify this

Correct answer: D

Rationale: Age can magnify pre-existing compulsive tendencies. If the client was detail-oriented about food earlier in life, this behavior may intensify with aging. It's important to acknowledge and address the client's concerns respectfully. Choices A, B, and C are incorrect because the daughter's observations do not necessarily point to depression, the compulsiveness about food does not indicate new cognitive decline without further assessment, and obsessiveness with food is not specifically common in diabetic clients.

3. A client with a urinary tract infection is prescribed ciprofloxacin. What is the nurse's priority teaching?

• A. Take the medication with a full glass of water.
• B. Avoid direct sunlight while taking the medication.
• C. Take the medication with meals to prevent nausea.
• D. Discontinue the medication if you experience dizziness.

Correct answer: A

Rationale: The correct answer is A: 'Take the medication with a full glass of water.' It is crucial for the nurse to teach the client to take ciprofloxacin with a full glass of water to prevent crystalluria, a potential side effect of the medication. Choice B is incorrect because ciprofloxacin does not require avoiding direct sunlight. Choice C is incorrect as taking the medication with meals is not necessary to prevent nausea. Choice D is incorrect as dizziness is not a common reason to discontinue ciprofloxacin.

4. The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?

• A. Encourage the client to ambulate
• B. Apply a warm compress to the left leg
• C. Elevate the client's left leg
• D. Administer a prescribed anticoagulant

Correct answer: C

Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.

5. Before administering digoxin to a client with heart failure, what is the most important assessment for the nurse to perform?

• A. Check the client's blood pressure
• B. Monitor the client's heart rate
• C. Assess the client's respiratory rate
• D. Review the client's potassium level

Correct answer: B

Rationale: The correct answer is to monitor the client's heart rate. Digoxin slows the heart rate, so it is crucial to assess the heart rate before administering the medication. If the heart rate is below 60 beats per minute, the dose should be held, and the healthcare provider should be notified. Checking the blood pressure (Choice A) is important but not as crucial as monitoring the heart rate in this case. Assessing the respiratory rate (Choice C) is not directly related to the action of digoxin. Reviewing the client's potassium level (Choice D) is important for clients taking digoxin due to the risk of hypokalemia, but assessing the heart rate takes priority.

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