Nursing Elites

1. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD) who is prescribed home oxygen. Which of the following statements should the nurse make?

• A. Check your oxygen equipment daily for proper function.
• B. Increase the oxygen flow rate if you feel short of breath.
• C. Store your oxygen tanks lying flat on the floor.
• D. It is safe to smoke as long as you are more than 10 feet from the oxygen source.

Correct answer: A

Rationale: The correct statement for the nurse to make is to advise the client to check the oxygen equipment daily for proper function. This is crucial to ensure the client's home oxygen therapy is working effectively and safely. Choice B is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored upright, not lying flat. Choice D is incorrect and unsafe advice, as smoking near an oxygen source can lead to a fire hazard.

2. A nurse is caring for a client who has a pressure ulcer. Which of the following findings should the nurse report to the provider?

• A. Eschar
• B. Slough
• C. Granulation tissue
• D. Undermining

Correct answer: D

Rationale: The correct answer is D, 'Undermining.' Undermining occurs when the tissue under the wound edges erodes, indicating poor healing progress. This finding should be reported to the provider as it suggests delayed wound healing and may require intervention. Choice A, 'Eschar,' is a thick, hard, black/brown necrotic tissue that forms over a wound. While it indicates a non-healing wound, it is not as concerning as undermining. Choice B, 'Slough,' is a soft, moist, yellow/white tissue that is also a sign of necrosis. While the presence of slough indicates the need for wound cleaning and debridement, it is not as critical to report as undermining. Choice C, 'Granulation tissue,' is new tissue that forms during wound healing and is a positive sign. The presence of granulation tissue indicates that the wound is progressing through the healing stages and is not a finding that requires immediate reporting to the provider.

3. A client is immediately postoperative following a hip arthroplasty. Which of the following positions should the nurse maintain for the client?

• A. Supine with legs extended
• B. Semi-Fowler's position with legs bent
• C. Lateral position with an abduction pillow between the legs
• D. Prone with legs elevated

Correct answer: C

Rationale: The correct position for a client immediately postoperative following a hip arthroplasty is the lateral position with an abduction pillow between the legs. This position helps prevent dislocation of the hip prosthesis and maintains proper alignment of the hip joint. Supine position with legs extended (Choice A) may put stress on the hip joint, Semi-Fowler's position with legs bent (Choice B) may not provide adequate support and alignment, and prone position with legs elevated (Choice D) is not recommended after hip arthroplasty as it can compromise the surgical site and increase the risk of complications.

4. A client with liver cirrhosis is experiencing confusion. Which of the following laboratory values should the nurse report to the provider?

• A. Bilirubin 0.8 mg/dL
• B. Ammonia 145 mcg/dL
• C. Albumin 4 g/dL
• D. Hemoglobin 13.5 g/dL

Correct answer: B

Rationale: The correct answer is B: Ammonia 145 mcg/dL. An elevated ammonia level can indicate hepatic encephalopathy in clients with liver cirrhosis, leading to confusion. Bilirubin (Choice A) is within the normal range, indicating adequate liver function. Albumin (Choice C) and Hemoglobin (Choice D) levels are also within normal limits and are not directly related to the client's confusion in this scenario.

5. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis.
• B. Administer flumazenil to the client.
• C. Evaluate the client for further suicidal behavior.
• D. Initiate seizure precautions for the client.

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.

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