Nursing Elites

1. A client is reinforcing teaching with a nurse about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

• A. The client exhales deeply before inhaling
• B. The client attempts to elevate the cylinder by inhaling deeply
• C. The client inhales quickly through the spirometer
• D. The client inhales several short breaths

Correct answer: B

Rationale: The correct answer is B because inhaling deeply and slowly elevates the cylinder on the spirometer, promoting lung expansion. Choice A is incorrect as exhaling deeply before inhaling is not the correct technique for using an incentive spirometer. Choice C is incorrect as inhaling quickly through the spirometer does not promote optimal lung expansion. Choice D is incorrect as inhaling several short breaths does not facilitate the proper use of an incentive spirometer.

2. How should a healthcare professional assess a patient with hyperkalemia?

• A. Monitor ECG and administer insulin
• B. Monitor blood glucose levels and provide fluids
• C. Monitor for muscle weakness and administer calcium gluconate
• D. Monitor electrolyte levels and provide potassium supplements

Correct answer: A

Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels. Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia. Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia. Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.

3. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

4. A healthcare professional is caring for a client with coronary artery disease (CAD) who is prescribed aspirin. Which of the following findings should the healthcare professional report to the provider?

• A. A history of gastrointestinal bleeding
• B. A history of hypertension
• C. A platelet count of 180,000/mm³
• D. A prothrombin time (PT) of 12 seconds

Correct answer: A

Rationale: The correct answer is A: A history of gastrointestinal bleeding. Patients with a history of gastrointestinal bleeding are at increased risk of complications when taking aspirin due to its effects on platelet function and the gastrointestinal tract. Reporting this finding to the provider is crucial to ensure patient safety. Choices B, C, and D are not directly related to the increased risk associated with aspirin use in patients with a history of gastrointestinal bleeding, making them less relevant in this scenario. While monitoring platelet count and PT are important in patients taking aspirin, a history of gastrointestinal bleeding takes precedence as it directly impacts the safety and effectiveness of aspirin therapy in this client.

5. A client with an NG tube is reporting nausea and a decrease in gastric secretions. What is the nurse's first action?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client onto their left side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This helps alleviate blockages and can improve the client's symptoms. Increasing the suction pressure (Choice A) may exacerbate the issue and cause further discomfort. Turning the client onto their left side (Choice C) is not directly related to addressing the reported symptoms. Replacing the NG tube with a new one (Choice D) should be considered only after attempting initial interventions like irrigation.

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