Nursing Elites

1. A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Administer oxygen at 2 L/min via nasal cannula
• B. Encourage pursed-lip breathing
• C. Position the client in high Fowler's position
• D. Encourage deep breathing and coughing

Correct answer: B

Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.

2. What are the key interventions for managing a patient with asthma?

• A. Administer bronchodilators and monitor oxygen levels
• B. Encourage deep breathing exercises
• C. Provide corticosteroids and monitor for respiratory distress
• D. Provide antihistamines and monitor blood pressure

Correct answer: A

Rationale: The correct answer is A: Administer bronchodilators and monitor oxygen levels. Asthma management involves using bronchodilators to help open the airways and improve breathing. Monitoring oxygen levels is essential to ensure the patient is getting enough oxygen. Choice B, encouraging deep breathing exercises, can be helpful for some respiratory conditions but is not a key intervention for managing an acute asthma attack. Choice C, providing corticosteroids and monitoring for respiratory distress, is important for long-term asthma management and severe exacerbations but is not the immediate key intervention during an acute attack. Choice D, providing antihistamines and monitoring blood pressure, is not typically indicated for asthma management as asthma is primarily an airway disease, not a histamine-mediated condition.

3. A nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?

• A. Restrict the client's fluid intake.
• B. Monitor the client's deep-tendon reflexes.
• C. Place the client in the lithotomy position.
• D. Encourage the client to ambulate frequently.

Correct answer: B

Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.

4. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

5. Which dietary advice is most appropriate for a client with chronic kidney disease?

• A. Increase intake of fruits and vegetables
• B. Limit intake of potassium-rich foods
• C. Increase intake of dairy products
• D. Reduce intake of protein-rich foods

Correct answer: B

Rationale: The most appropriate dietary advice for a client with chronic kidney disease is to limit intake of potassium-rich foods. In chronic kidney disease, the kidneys have difficulty filtering potassium from the blood, leading to high levels that can be harmful. Therefore, reducing potassium intake is crucial to prevent complications. Choices A, C, and D are not the best options for individuals with chronic kidney disease. Increasing intake of fruits and vegetables (choice A) may actually increase potassium consumption. Increasing intake of dairy products (choice C) can lead to higher phosphorus and potassium levels. Reducing protein-rich foods (choice D) is not the primary focus in the early stages of chronic kidney disease, as protein is necessary for overall health unless kidney function declines significantly.

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