Nursing Elites

1. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

• A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
• B. Nail polish should not be used near a client who is receiving oxygen
• C. A 'No Smoking' sign should be placed on the front door
• D. Cotton bedding and clothing should be replaced with items made from wool

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

2. What are the risk factors for developing hypertension?

• A. High sodium diet and lack of physical activity
• B. Low potassium intake and excessive alcohol consumption
• C. Frequent exercise and low cholesterol diet
• D. Smoking and family history

Correct answer: A

Rationale: The correct answer is A: High sodium diet and lack of physical activity. These are established risk factors for developing hypertension as they contribute to elevated blood pressure. Choice B, low potassium intake and excessive alcohol consumption, may also impact blood pressure but are not as strongly associated with hypertension as high sodium intake and lack of physical activity. Choice C, frequent exercise and a low cholesterol diet, are actually beneficial for reducing the risk of hypertension. Choice D, smoking and family history, are more closely linked to other health conditions such as cardiovascular diseases, rather than being primary risk factors for hypertension.

3. A nurse is caring for a client who is in the early stages of hypovolemic shock. Which of the following findings should the nurse expect?

• A. Heart rate 60/min
• B. Increased urinary output
• C. Increased respiratory rate
• D. Hypothermia

Correct answer: C

Rationale: In the early stages of hypovolemic shock, the body initiates compensatory mechanisms to maintain perfusion. One of these mechanisms is an increased respiratory rate to improve oxygen delivery. This helps to offset the decreased circulating blood volume. A heart rate of 60/min (choice A) is not expected in hypovolemic shock; instead, tachycardia is a common finding due to the body's attempt to maintain cardiac output. Increased urinary output (choice B) is not typically seen in hypovolemic shock as the body tries to conserve fluid. Hypothermia (choice D) is usually a late sign of shock when the body's compensatory mechanisms are failing, and perfusion is severely compromised.

4. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

• A. Increased speech
• B. Lack of sleep
• C. Agitation
• D. Poor concentration

Correct answer: B

Rationale: The correct answer is lack of sleep (choice B). In acute mania, lack of sleep can exacerbate symptoms, lead to exhaustion, and pose serious risks to the client's well-being. Addressing the client's sleep deprivation is a priority as it can impact their overall health and recovery. Increased speech (choice A) and agitation (choice C) are common in acute mania but do not pose immediate physical risks like lack of sleep. Poor concentration (choice D) is also a symptom of acute mania but addressing sleep deprivation takes precedence due to its severe consequences.

5. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Administer the medication into the client's nondominant arm.
• B. Pull the skin laterally before inserting the needle.
• C. Massage the injection site after administration.
• D. Pinch the skin between the thumb and forefinger.

Correct answer: D

Rationale: The correct action the nurse should take when administering enoxaparin subcutaneously is to pinch the skin between the thumb and forefinger. Pinching the skin helps to lift the subcutaneous tissue, reducing the risk of injecting into the muscle. Choices A, B, and C are incorrect. Choice A is not relevant as the injection site for enoxaparin is typically in the abdomen or thigh, not the arm. Choice B is incorrect as pulling the skin laterally is not a recommended technique for subcutaneous injections. Choice C is also incorrect as massaging the injection site after administration can increase the risk of bleeding or bruising.

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