Nursing Elites

1. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to breathe deeply and cough every 4 hours.
• B. Provide a diet that is high in carbohydrates and low in protein.
• C. Teach the client pursed-lip breathing technique.
• D. Restrict the client's fluid intake to 1,500 mL per day.

Correct answer: C

Rationale: The correct answer is C: Teach the client pursed-lip breathing technique. Pursed-lip breathing helps clients with COPD improve oxygenation and reduce shortness of breath. Choice A is incorrect because deep breathing and coughing are not recommended every 4 hours for clients with COPD. Choice B is incorrect because a diet high in carbohydrates and low in protein is not specifically indicated for COPD. Choice D is incorrect because fluid restriction is not a standard intervention for COPD unless the client has comorbid conditions that necessitate it.

2. A client who practices Orthodox Judaism informs the nurse that he cannot eat certain foods during the Passover holiday. Which of the following actions should the nurse include in the plan of care?

• A. Serve chicken with cream sauce
• B. Avoid serving fish with fins and scales
• C. Provide unleavened bread
• D. Avoid serving foods containing lamb

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism adhere to specific dietary restrictions, which include consuming unleavened bread. Providing unleavened bread aligns with the client's religious beliefs and dietary requirements. Choices A, B, and D are incorrect. Serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not directly related to the dietary restrictions observed during the Passover holiday in Orthodox Judaism.

3. A nurse is caring for a client with heart failure receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate 60/min.
• B. Blood pressure 110/70 mm Hg.
• C. Serum potassium 4 mEq/L.
• D. Blood pressure 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.

4. A nurse is caring for a client who is receiving chemotherapy. The client's platelet count is 25,000/mm3. Which of the following actions should the nurse take?

• A. Administer aspirin for discomfort
• B. Check the client's temperature every 4 hr
• C. Monitor the client's urine output
• D. Check for stool in the client's colostomy bag every 2 hr

Correct answer: B

Rationale: Clients with a low platelet count are at risk of bleeding and infection. Monitoring the client's temperature every 4 hours is crucial to detect early signs of infection, as they may not be able to mount a typical immune response due to their compromised platelet count. Administering aspirin (choice A) is contraindicated in clients with low platelet counts as it can further increase the risk of bleeding. Monitoring urine output (choice C) and checking for stool in a colostomy bag (choice D) are important aspects of care but are not the priority in a client with low platelet count.

5. What is the primary action when a healthcare provider discovers a patient has fallen?

• A. Assess the patient for injuries
• B. Call for help immediately
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: When a healthcare provider discovers a patient has fallen, the primary action should be to assess the patient for injuries. This is crucial to determine the extent of harm and if immediate treatment is necessary. Calling for help is important, but assessing the patient's condition takes precedence to ensure the patient's safety and well-being. While documenting the fall and notifying the healthcare provider are essential steps, they come after assessing the patient's injuries.

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