Nursing Elites

1. A nurse is providing discharge instructions to a client with home oxygen therapy. What safety measure should the nurse emphasize?

• A. Allow smoking in designated outdoor areas
• B. Keep oxygen tanks upright and away from heat sources
• C. Store oxygen tanks in a closet when not in use
• D. Keep oxygen equipment at least 10 feet away from open flames

Correct answer: B

Rationale: The correct safety measure that the nurse should emphasize is to keep oxygen tanks upright and away from heat sources. This is crucial to prevent the risk of fire or explosion. Choice A is incorrect as smoking near oxygen can lead to a fire hazard. Choice C is also incorrect as storing oxygen tanks in enclosed spaces can be dangerous. Choice D, although related to safety, does not address the immediate risk of keeping oxygen tanks away from heat sources.

2. A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. A fasting blood glucose of 90 mg/dL
• B. A blood glucose level of 200 mg/dL
• C. A hemoglobin A1c of 6%
• D. A fasting blood glucose of 100 mg/dL

Correct answer: B

Rationale: The correct answer is B. A blood glucose level of 200 mg/dL indicates hyperglycemia, which may necessitate insulin adjustment to better control the client's blood sugar levels. A fasting blood glucose of 90 mg/dL (choice A) is within the normal range, a hemoglobin A1c of 6% (choice C) is indicative of good long-term blood sugar control, and a fasting blood glucose of 100 mg/dL (choice D) is also within the normal range. Therefore, these findings do not require immediate reporting to the provider.

3. A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?

• A. The client advances the cane 18 inches in front of the foot
• B. The client holds the cane in the left hand
• C. The client advances the cane and the right leg simultaneously
• D. The client holds the cane with the elbow flexed at 60°

Correct answer: B

Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.

4. A nurse is reinforcing teaching to a client with hypertension. What lifestyle change should be emphasized?

• A. Increase intake of sodium-rich foods
• B. Limit intake of high-fat foods
• C. Reduce intake of caffeinated beverages
• D. Eat high-protein foods to lower blood pressure

Correct answer: B

Rationale: The correct lifestyle change that should be emphasized for a client with hypertension is to limit the intake of high-fat foods. High-fat foods can contribute to high blood pressure, so reducing their consumption is important in managing hypertension. Choice A is incorrect because increasing intake of sodium-rich foods can worsen hypertension due to their effect on blood pressure. Choice C is incorrect as caffeinated beverages can also elevate blood pressure. Choice D is incorrect because while high-protein foods can be beneficial, they do not directly lower blood pressure like reducing high-fat foods would.

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

• A. Drainage of 75 mL in the first hour after surgery.
• B. Constant bubbling in the water seal chamber.
• C. Tidaling in the water seal chamber.
• D. Client report of pain at the chest tube insertion site.

Correct answer: B

Rationale: Constant bubbling in the water seal chamber indicates an air leak, which should be reported to the provider. This finding suggests that the chest tube system is not functioning properly, leading to potential complications such as pneumothorax. Drainage of 75 mL in the first hour after surgery is within the expected range for a chest tube. Tidaling in the water seal chamber is a normal fluctuation and indicates proper functioning of the system. Client report of pain at the chest tube insertion site is expected after surgery and can be managed with appropriate pain management measures.

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