Nursing Elites

1. A client with HIV and neutropenia requires specific care from the nurse. Which of the following precautions should the nurse take while caring for this client?

• A. Wear an N95 respirator while caring for the client.
• B. Use a dedicated stethoscope for the client.
• C. Insert an indwelling urinary catheter to monitor urinary output.
• D. Monitor the client’s vital signs every 8 hours.

Correct answer: B

Rationale: Using dedicated equipment for a neutropenic client, such as a stethoscope, helps prevent infections. Neutropenic clients have a weakened immune system, making them vulnerable to infections from common pathogens. Wearing an N95 respirator is not necessary unless airborne precautions are required. Inserting a urinary catheter should be avoided unless necessary to prevent introducing pathogens. Monitoring vital signs should be done more frequently, typically every 4 hours, to promptly identify any changes in the client's condition.

2. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Perform palpation before auscultation
• B. Perform percussion before auscultation
• C. Perform palpation after auscultation
• D. Perform inspection after auscultation

Correct answer: C

Rationale: The correct answer is C: Perform palpation after auscultation. When conducting an abdominal assessment, the correct sequence is inspection, auscultation, percussion, and then palpation. Inspecting the abdomen allows the nurse to observe any visible abnormalities, followed by listening for bowel sounds during auscultation. Percussion helps assess the density of abdominal contents before palpation for tenderness, masses, or organ enlargement. Choices A, B, and D are incorrect because palpation should always come last in the sequence of an abdominal assessment.

3. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.

4. A healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD) receiving oxygen therapy. Which of the following findings indicates oxygen toxicity?

• A. Oxygen saturation 94%
• B. Decreased respiratory rate
• C. Wheezing
• D. Peripheral cyanosis

Correct answer: B

Rationale: The correct answer is B: Decreased respiratory rate. In clients with COPD, especially when receiving oxygen therapy, a decreased respiratory rate is indicative of oxygen toxicity. This occurs because their respiratory drive is often dependent on low oxygen levels. Oxygen saturation of 94% is within an acceptable range and does not necessarily indicate oxygen toxicity. Wheezing is more commonly associated with airway narrowing or constriction, while peripheral cyanosis is a sign of decreased oxygen levels in the peripheral tissues, not oxygen toxicity.

5. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?

• A. Restrict protein intake to less than 40 g/day
• B. Initiate seizure precautions for the client
• C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
• D. Encourage the client to ambulate twice per day

Correct answer: B

Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.

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