Nursing Elites

1. A nurse is preparing to perform a focused respiratory assessment on a client with COPD. What is an expected finding?

• A. Normal respiratory rate
• B. Nasal flaring
• C. Decreased breath sounds
• D. Increased breath sounds

Correct answer: B

Rationale: Nasal flaring is an expected finding in clients with COPD who are experiencing respiratory distress. Nasal flaring is a sign of increased work of breathing and respiratory distress, commonly seen in clients with COPD exacerbation. Choices A, C, and D are incorrect. A normal respiratory rate would not be an expected finding in a client with COPD, as they often have an increased respiratory rate. Decreased breath sounds could indicate diminished airflow but are not typically a common finding in COPD. Increased breath sounds are not typical in COPD and could indicate other conditions like pneumonia.

2. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Use a special mattress for the client
• C. Keep the client on bedrest
• D. Encourage the client to remain in one position

Correct answer: B

Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.

3. A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?

• A. Avoid ambulation to prevent injury
• B. Use compression stockings
• C. Use a heating pad for comfort
• D. Elevate the client's legs on a pillow

Correct answer: B

Rationale: The correct intervention to reduce the risk of deep vein thrombosis (DVT) after surgery is to use compression stockings. Compression stockings help prevent DVT by promoting venous return, which reduces the likelihood of blood pooling in the legs and forming clots. Choices A, C, and D are incorrect because avoiding ambulation can actually increase the risk of DVT, using a heating pad does not directly address DVT prevention, and elevating the client's legs on a pillow alone may not provide sufficient compression to prevent DVT.

4. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. Which term should the nurse use to document this finding?

• A. Papule
• B. Macule
• C. Nodule
• D. Tumor

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion is less than 0.5cm, fitting the description of a macule. A papule (choice A) is a solid, elevated lesion less than 0.5 cm in diameter. A nodule (choice C) is a solid, elevated lesion that is 0.5 cm or larger in diameter. A tumor (choice D) refers to a mass of abnormal tissue growth, which is not applicable in this scenario.

5. A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?

• A. Bruising at the IV site
• B. Edema at the IV site
• C. Warmth along the IV site
• D. Pallor at the IV site

Correct answer: B

Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.

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