Nursing Elites

1. A nurse is providing discharge teaching for a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?

• A. Use pursed-lip breathing during activities
• B. Avoid physical activity
• C. Perform weight-bearing exercises
• D. Use a humidifier while sleeping

Correct answer: A

Rationale: Corrected Rationale: The nurse should instruct the client to use pursed-lip breathing during activities to help improve oxygenation. Pursed-lip breathing can keep the airways open longer, facilitating better oxygen exchange and making it easier to exhale carbon dioxide. Choice B is incorrect as physical activity, within the client's limitations, is beneficial for maintaining overall health. Choice C is incorrect as weight-bearing exercises are important for bone health but not directly related to improving oxygenation in COPD. Choice D is incorrect as using a humidifier while sleeping can help with moisture in the airways but does not directly impact oxygenation in COPD.

2. A client is being taught about measures to promote sleep for insomnia. Which client statement indicates understanding?

• A. I will take naps during the day to help me sleep at night
• B. I should drink caffeine to help me stay awake during the day
• C. I should reduce my fluid intake 2 hours before bedtime
• D. I should exercise right before bed to tire myself out

Correct answer: C

Rationale: The correct answer is C. By reducing fluid intake 2 hours before bedtime, the client can prevent nighttime awakenings to urinate, which promotes better sleep. Napping during the day (choice A) may interfere with nighttime sleep. Drinking caffeine (choice B) can disrupt sleep patterns. Exercising right before bed (choice D) can actually stimulate the body and make it harder to fall asleep.

3. During a focused assessment for a client with dysrhythmias, what indicates ineffective cardiac contractions?

• A. Increased heart rate
• B. Pulse deficit
• C. Elevated blood pressure
• D. Bounding pulse

Correct answer: B

Rationale: A pulse deficit is a crucial finding in clients with dysrhythmias as it indicates ineffective cardiac contractions. A pulse deficit occurs when the apical heart rate is faster than the radial pulse rate, suggesting that some heartbeats are not generating a pulse. This can be a sign of serious heart conditions like atrial fibrillation or heart failure. The other options, such as an increased heart rate (choice A), elevated blood pressure (choice C), and bounding pulse (choice D), do not specifically indicate ineffective cardiac contractions and are not directly associated with dysrhythmias.

4. While documenting client care, which entry should the nurse identify as an example of implementing client care?

• A. Documenting the client's pain level
• B. Monitoring the client's urine output
• C. Assessing the client's range of motion
• D. Contacting the provider to report client findings

Correct answer: D

Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.

5. A client is being taught how to use a cane. Which instruction should the nurse include?

• A. Use the cane on the stronger side
• B. Use the cane on the weaker side
• C. Ensure the cane has a rubber tip
• D. Hold the cane 1-2 inches from the ground

Correct answer: A

Rationale: The correct answer is to use the cane on the stronger side. This instruction is important because it provides better support and balance. Placing the cane on the stronger side helps to shift weight off the weaker or injured side, reducing the risk of falls and promoting stability. Choices B, C, and D are incorrect. Using the cane on the weaker side would not provide optimal support. While ensuring the cane has a rubber tip and holding it 1-2 inches from the ground are important, they are not as crucial as using the cane on the stronger side for proper support and balance.

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