Nursing Elites

1. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?

• A. I have a sharp pain in my chest when I take a breath.
• B. I have been coughing up foul-tasting, brown, thick sputum.
• C. I have been sweating all day.
• D. I feel hot off and on.

Correct answer: B

Rationale: Coughing up foul-tasting, brown, thick sputum suggests a possible abscess or secondary infection, requiring attention. Choice A may indicate pleurisy, but the focus should be on the sputum. Choice C may be non-specific and could be related to the infection or fever. Choice D is non-specific and may be expected during an infection.

2. A nurse is reinforcing teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate?

• A. Drink carbonated beverages.
• B. Decrease fiber intake.
• C. Use bronchodilators after meals.
• D. Increase protein intake.

Correct answer: D

Rationale: The correct answer is to instruct the client to increase protein intake. This is appropriate because increasing protein intake can help maintain muscle mass and strength in clients with COPD. Option A, 'Drink carbonated beverages,' is incorrect as carbonated beverages can exacerbate COPD symptoms. Option B, 'Decrease fiber intake,' is also incorrect as fiber is important for digestion and should not be decreased unless specifically advised by a healthcare provider. Option C, 'Use bronchodilators after meals,' is incorrect because bronchodilators are typically used before meals to help open the airways for better breathing, not after meals.

3. A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?

• A. Why don't you switch to formula to ensure your baby is eating enough?
• B. It is common for new mothers to worry that they are not producing enough milk for their baby.
• C. A healthy newborn can lose 6% of his birth weight before starting to gain weight.
• D. Your newborn will need to remain in the hospital so his weight can be monitored.

Correct answer: C

Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.

4. What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?

• A. Maintain adequate hydration
• B. Assist the client to turn, deep breathe, and cough
• C. Ambulate the client within 12 hours
• D. Splint the incision

Correct answer: B

Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.

5. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication:

• A. Can predispose to dysrhythmias
• B. May lead to oliguria
• C. May cause irritability and anxiety
• D. Sometimes alters consciousness

Correct answer: A

Rationale: The correct answer is A: Hypokalemia increases the risk of dysrhythmias when taking digoxin, making potassium intake crucial. Digoxin toxicity is more likely in patients with low potassium levels, leading to an increased risk of dysrhythmias. Choices B, C, and D are incorrect because hypokalemia in combination with digoxin is primarily associated with dysrhythmias rather than oliguria, irritability, anxiety, or alteration of consciousness.

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