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. What is a crucial nursing responsibility when caring for a patient with a central line?

• A. Flush the line with saline
• B. Monitor for infection
• C. Monitor fluid balance
• D. Replace the central line

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is a crucial nursing responsibility. This is essential to prevent complications such as bloodstream infections. While flushing the line with saline and monitoring fluid balance are important aspects of care, they are not as critical as monitoring for infection. Replacing the central line is only done when necessary due to complications or at the end of its recommended use.

3. A nurse is caring for a client who has a chest tube. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the past 24 hours.
• B. Intermittent bubbling in the water seal chamber.
• C. Continuous bubbling in the water seal chamber.
• D. Tidaling in the water seal chamber.

Correct answer: C

Rationale: Continuous bubbling in the water seal chamber should be reported to the provider as it can indicate an air leak. This finding suggests that air is escaping from the pleural space, which can lead to lung collapse or pneumothorax. Drainage of 75 mL in the past 24 hours is within the expected range for a client with a chest tube and is not a cause for concern. Intermittent bubbling in the water seal chamber is a normal finding that indicates the system is functioning properly. Tidaling in the water seal chamber is also an expected finding that shows the fluctuation of fluid with the client's breathing and is not alarming.

4. A client has a new prescription for levothyroxine. Which of the following findings should the nurse monitor for as a potential adverse effect of the medication?

• A. Increased heart rate.
• B. Weight loss.
• C. Hyperthermia.
• D. Decreased deep-tendon reflexes.

Correct answer: A

Rationale: Corrected Rationale: An increased heart rate is a common adverse effect of levothyroxine due to its role in boosting metabolism. Choice B, weight loss, is actually a therapeutic effect of levothyroxine as it helps in managing hypothyroidism by increasing the metabolic rate. Hyperthermia (Choice C) is not a typical adverse effect of levothyroxine. Decreased deep-tendon reflexes (Choice D) are not associated with levothyroxine use.

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

• A. Heart rate of 78/min.
• B. Vision changes.
• C. Respiratory rate of 16/min.
• D. Blood pressure of 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B: Vision changes. Vision changes are a classic sign of digoxin toxicity and should be reported immediately to the provider for further evaluation and management. A heart rate of 78/min, a respiratory rate of 16/min, and a blood pressure of 120/80 mm Hg are within normal ranges and are not typically associated with digoxin toxicity. Therefore, they would not be the priority findings to report in this situation.

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