Nursing Elites

1. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

• A. Raise the affected extremity above the level of the heart.
• B. Immobilize the affected extremity with a splint
• C. Apply ice to the bite area
• D. Apply a tourniquet to the affected extremity.

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

2. A healthcare provider collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the healthcare provider include in communications with the respiratory therapist prior to the tests? (Select ONE that does not apply)

• A. I ensured the client did not use bronchodilator medication within the specified timeframe.
• B. The client is prepared to undergo the examination in radiology.
• C. Physical therapy has approved the client for treadmill exercise.
• D. I instructed the client not to smoke for the required duration before the test.

Correct answer: C

Rationale: For accurate pulmonary function tests (PFTs), it is essential to communicate that the client did not use bronchodilators within the specified timeframe, did not smoke for the required duration before the test, and can comply with different breathing maneuvers. The use of a treadmill is not part of the PFT procedure and is unrelated to the testing process. Therefore, communicating about the client's ability to run on a treadmill is not relevant to the pulmonary function tests being conducted by the respiratory therapist.

3. During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?

• A. Dullness
• B. Resonance
• C. Tympany
• D. Flatness

Correct answer: B

Rationale: In a client with chronic bronchitis, the nurse or healthcare provider would expect to hear resonant sounds upon percussion. Resonance is the normal percussion sound heard over healthy lung tissue. The other options such as dullness, tympany, and flatness are associated with different conditions or abnormalities, not typically expected in chronic bronchitis.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 22 breaths per minute
• C. Client reports shortness of breath
• D. Client's respiratory rate decreases to 10 breaths per minute

Correct answer: D

Rationale: A decrease in the client's respiratory rate to 10 breaths per minute, while receiving oxygen therapy for COPD, is a concerning finding that may indicate carbon dioxide retention and respiratory depression. This situation requires immediate action to prevent further complications. An oxygen saturation of 90% is within an acceptable range for COPD patients on oxygen therapy. A respiratory rate of 22 breaths per minute and reports of shortness of breath are common in clients with COPD and may not necessitate immediate action unless accompanied by other concerning symptoms.

5. A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?

• A. Increase protein intake.
• B. Limit fluid intake to 1500 mL/day.
• C. Consume a low-sodium diet.
• D. Take a daily multivitamin.

Correct answer: C

Rationale: For a client with cirrhosis experiencing ascites, the nurse should instruct them to consume a low-sodium diet. This dietary modification helps reduce fluid retention and manage ascites by decreasing the amount of sodium in the body, which helps prevent fluid accumulation in the abdomen. Limiting sodium intake is crucial in managing ascites and preventing further complications in clients with cirrhosis.

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