Nursing Elites

1. A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?

• A. Oxygen equipment
• B. Incentive spirometer
• C. Pulse oximeter
• D. Sterile dressing

Correct answer: B

Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.

2. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?

• A. Lethargy
• B. Increased pulse rate and blood pressure
• C. Muscle weakness
• D. Muscle irritability

Correct answer: C

Rationale: Muscle weakness is a hallmark symptom of hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can affect muscle function. The decreased potassium levels can lead to muscle weakness, cramping, and even paralysis. These symptoms can impact various muscle groups in the body, making muscle weakness the most significant symptom to monitor and address in patients with hypokalemia.

3. When caring for a client who is on contact precautions, which of the following measures should the nurse include in the teaching?

• A. Remove the protective gown after leaving the client's room.
• B. Place the client in a room with negative pressure.
• C. Wear gloves when providing care to the client.
• D. Wear a mask when in the client's room.

Correct answer: C

Rationale: Contact precautions are used for clients with known or suspected infections that are spread by direct or indirect contact. The most important measure for healthcare workers when caring for a client on contact precautions is to wear gloves when providing care. This helps prevent the transmission of infectious agents between the client and the healthcare worker. Removing the protective gown after leaving the client's room, placing the client in a room with negative pressure, and wearing a mask when in the client's room are not specific to contact precautions and may not be necessary for all clients on contact precautions.

4. A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

• A. Urine output of 20 ml/hr.
• B. Montevideo units constantly at 300 mm Hg.
• C. FHR pattern showing absent variability.
• D. Contractions occurring every 5 minutes and lasting 30 seconds.

Correct answer: B

Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.

5. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:

• A. Tachypnea
• B. Eupnea
• C. Orthopnea
• D. Hyperventilation

Correct answer: C

Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.

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