Nursing Elites

1. A client is being instructed on how to perform pursed-lip breathing. Which of the following should be included in the plan of care?

• A. Take quick breaths upon inhalation.
• B. Place your hand over your stomach.
• C. Take a deep breath in through your nose.
• D. Puff your cheeks upon exhalation.

Correct answer: C

Rationale: Pursed-lip breathing is a breathing technique that involves inhaling slowly through the nose and exhaling gently through pursed lips. This technique helps improve breathing efficiency and can be beneficial for individuals with respiratory conditions. Instructing the client to take a deep breath in through the nose is essential for proper execution of pursed-lip breathing, making choice C the correct answer.

2. What is the appropriate route of administration for insulin?

• A. Intramuscular
• B. Intradermal
• C. Subcutaneous
• D. Intravenous

Correct answer: C

Rationale: The appropriate route of administration for insulin is subcutaneous. Subcutaneous injections are commonly used for insulin administration due to the slower absorption rate compared to intramuscular or intravenous routes. This slower absorption rate allows for better control of blood glucose levels. Intramuscular administration is not ideal for insulin as it can lead to rapid absorption and fluctuations in blood sugar levels. Intradermal injections are shallow and used for skin testing rather than insulin administration. Intravenous administration of insulin is not recommended due to the rapid and unpredictable effects it can have on blood glucose levels.

3. A healthcare professional is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, and HCO3 22 mm Hg. The healthcare professional should recognize that the client is experiencing which of the following acid-base imbalances?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: B

Rationale: The ABG results show a high pH (alkalosis) along with low PaCO2 and normal HCO3 levels, indicating respiratory alkalosis. In this condition, there is excessive loss of carbon dioxide (as seen by the low PaCO2) leading to a decrease in carbonic acid concentration and subsequent increase in pH. Metabolic acidosis or alkalosis would involve primary changes in bicarbonate levels, which are not predominant in this case.

4. A patient requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

• A. Diabetes mellitus
• B. Shoulder presentation
• C. Postterm with oligohydramnios
• D. Chorioamnionitis

Correct answer: C

Rationale: Postterm pregnancy with oligohydramnios is a contraindication for the use of oxytocin due to the increased risk of uterine hyperstimulation and fetal distress. Oxytocin can further stress the fetus in this scenario, potentially leading to adverse outcomes. Therefore, it is crucial for the nurse to recognize this contraindication to ensure the safety of both the mother and the baby during labor.

5. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

• A. ''I am allergic to morphine.''
• B. ''I take antacids several times a day.''
• C. ''I had a blood clot in my leg several years ago.''
• D. ''It hurts to take a deep breath.''

Correct answer: B

Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.

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