Nursing Elites

1. During a follow-up home visit, the nurse observes that a client with chronic obstructive pulmonary disease (COPD) is using accessory muscles to breathe and has a pulse oximetry reading of 88%. What action should the nurse take first?

• A. Administer a prescribed bronchodilator
• B. Increase the oxygen flow rate
• C. Instruct the client to perform pursed-lip breathing
• D. Notify the healthcare provider immediately

Correct answer: C

Rationale: In this situation, the nurse should first instruct the client to perform pursed-lip breathing. Pursed-lip breathing helps improve oxygenation and decrease the work of breathing in clients with COPD. Administering a bronchodilator or increasing the oxygen flow rate may be necessary interventions but addressing the breathing technique through pursed-lip breathing is the initial action to optimize oxygenation. Notifying the healthcare provider immediately is not the first action indicated in this scenario; the nurse should intervene promptly to assist the client in improving breathing before escalating the situation.

2. The healthcare professional is developing a community health program to address the high rates of childhood asthma in a neighborhood. Which intervention should the healthcare professional prioritize?

• A. conducting home visits to identify asthma triggers
• B. distributing asthma education materials at schools
• C. holding workshops on asthma management for parents
• D. partnering with local healthcare providers to offer free asthma screenings

Correct answer: A

Rationale: The healthcare professional should prioritize conducting home visits to identify asthma triggers as it is crucial for reducing asthma attacks in children. By identifying triggers in the home environment, interventions can be implemented to create a safer living space for children with asthma. This approach directly addresses the root cause of asthma exacerbations. Distributing asthma education materials at schools is beneficial for raising awareness but may not address individual triggers. Holding workshops on asthma management for parents is valuable for education but does not directly tackle trigger identification. Partnering with local healthcare providers to offer free asthma screenings focuses on detection rather than prevention through trigger identification.

3. During a home visit, the nurse observes that an elderly client has a cluttered living environment and poor lighting. What should the nurse do first?

• A. suggest that the client hires a cleaning service
• B. assist the client in organizing the living space
• C. assess the client's risk for falls
• D. provide the client with information on home safety

Correct answer: C

Rationale: The correct first action for the nurse to take is to assess the client's risk for falls. A cluttered living environment and poor lighting are significant risk factors for falls in the elderly. By assessing the client's risk for falls, the nurse can identify potential hazards and implement appropriate interventions to prevent falls. Suggesting hiring a cleaning service or assisting in organizing the living space may address the symptoms but not the root cause of the fall risk. Providing information on home safety is important but should come after assessing the specific risk factors for falls in this scenario.

4. The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning properly?

• A. Continuous bubbling in the water-seal chamber.
• B. No fluctuation (tidaling) in the water-seal chamber.
• C. Intermittent bubbling in the suction control chamber.
• D. Drainage of clear, pale yellow fluid from the chest tube.

Correct answer: D

Rationale: The drainage of clear, pale yellow fluid from the chest tube is an indication of proper chest tube functioning. Clear, pale yellow fluid signifies normal drainage from the pleural space without any signs of infection or complications. Choices A, B, and C are incorrect because continuous bubbling in the water-seal chamber, no fluctuation in the water-seal chamber, and intermittent bubbling in the suction control chamber are all indications of potential issues or malfunctioning of the chest tube system, which would require further assessment and intervention.

5. The client with the sexually transmitted disease HPV reports having had prior sexually transmitted infections. Which response should the nurse provide?

• A. Emphasize that using safe sex practices removes the risk of transmission.
• B. Instruct the client of the importance of notifying sexual partners.
• C. Reassure that complications will not occur if infection is treated.
• D. Provide counseling that most contraceptives prevent against infection.

Correct answer: B

Rationale: Instructing the client about the importance of notifying sexual partners is crucial when dealing with sexually transmitted infections like HPV. This helps prevent the spread of the infection to others and promotes responsible sexual behavior. Choices A, C, and D are incorrect because while using safe sex practices is important, notifying sexual partners is more immediate and directly related to preventing the spread of the infection. Reassuring about complications and discussing contraceptives do not address the immediate need to notify partners.

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