Nursing Elites

1. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?

• A. Productive cough with green sputum
• B. Temperature of 37.1°C (98.8°F)
• C. Crackles in the lung bases
• D. Oxygen saturation of 95%

Correct answer: C

Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.

2. What is the most appropriate action when a patient is experiencing severe dehydration?

• A. Administer IV fluids
• B. Encourage oral fluids
• C. Monitor electrolytes
• D. Perform a neurological exam

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

3. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased bleeding tendencies. Providing a stool softener helps prevent constipation and straining during bowel movements, reducing the risk of bleeding. Encouraging the client to floss daily (Choice A) is important for oral hygiene but is not directly related to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to preventing infections in immunocompromised clients. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems but is not specifically targeted at managing thrombocytopenia.

4. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Polyuria
• C. Hypertension
• D. Weight loss

Correct answer: B

Rationale: Polyuria is the correct answer. Diabetes insipidus is characterized by the inability to concentrate urine, leading to excessive urination (polyuria) and thirst. Bradycardia (slow heart rate) is not typically associated with diabetes insipidus. While dehydration from the excessive urination can lead to hypotension rather than hypertension, and weight loss can occur due to fluid loss, the most specific and significant finding expected in diabetes insipidus is polyuria.

5. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

• A. Flush the tube with 30 mL of sterile water before each feeding.
• B. Check for gastric residuals every 4 hours.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Place the client in the left lateral position during feedings.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

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