Nursing Elites

1. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has been experiencing increasing shortness of breath. Which finding requires immediate intervention?

• A. A respiratory rate of 26 breaths per minute
• B. Use of accessory muscles for breathing
• C. Barrel chest appearance
• D. A pulse oximetry reading of 88%

Correct answer: D

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to improve oxygenation. Hypoxemia can lead to serious complications if not addressed promptly. While a respiratory rate of 26 breaths per minute and the use of accessory muscles for breathing are concerning in COPD, they do not indicate an immediate life-threatening situation. Similarly, a barrel chest appearance is a common finding in COPD and does not require urgent intervention compared to the critical need to address hypoxemia.

2. A client with diabetes mellitus is scheduled for surgery. What is the nurse's priority action when preparing this client for surgery?

• A. Ensure the client is NPO before surgery
• B. Monitor the client's blood glucose levels
• C. Administer the client's insulin as scheduled
• D. Teach the client about postoperative care

Correct answer: B

Rationale: The correct answer is B: Monitor the client's blood glucose levels. Clients with diabetes are at risk for perioperative complications related to blood glucose fluctuations. Monitoring blood glucose levels is crucial to maintaining proper management before, during, and after surgery. Option A is not the priority action as ensuring NPO status is a standard preoperative procedure for all clients. Option C could be important but is secondary to monitoring blood glucose levels. Option D is important but not the priority during the preoperative phase.

3. A client is diagnosed with chronic renal failure, and the nurse is teaching dietary modifications. What should be limited in this client's diet?

• A. Carbohydrates
• B. Fats
• C. Proteins
• D. Vitamins

Correct answer: C

Rationale: In chronic renal failure, proteins should be limited in the diet. When the kidneys are not functioning well, the buildup of protein byproducts can put additional stress on them. Limiting protein intake can help reduce the burden on the kidneys. Carbohydrates and fats do not need to be restricted in the same way as proteins. Vitamins are essential nutrients that should not be limited in the diet unless specified by a healthcare provider for a specific reason.

4. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A. Administer the medication in 2 separate injections
• B. Give the medication in the dorsal gluteal site
• C. Call to get a smaller volume ordered
• D. Check with the pharmacy for a liquid form of the medication

Correct answer: A

Rationale: Injections over 1 mL should be split into two separate injections for young children. This helps in preventing discomfort, ensuring proper absorption, and reducing the risk of tissue damage. Giving the medication in one injection of 2.0 ml might be too much for a 2-year-old child. Choices B and D are incorrect because the dorsal gluteal site is not recommended for children due to potential injury, and changing the form of medication might not be necessary if the volume can be adjusted. Choice C is unnecessary as splitting the dose into two injections is the appropriate action.

5. A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?

• A. Take phenytoin with antacids to reduce stomach upset.
• B. Maintain a consistent dosing schedule to prevent seizures.
• C. Monitor for excessive drowsiness and dizziness.
• D. Take the medication at bedtime to reduce seizure risk.

Correct answer: B

Rationale: The most important teaching the nurse should provide to a client prescribed phenytoin is to maintain a consistent dosing schedule to prevent seizures. Phenytoin is an antiepileptic drug, and missing doses can increase the risk of seizures. Option A is incorrect because antacids can interact with phenytoin and reduce its absorption. Option C is important but not the most critical teaching as compared to maintaining a consistent dosing schedule. Option D is incorrect because the timing of phenytoin administration should be consistent rather than specifically at bedtime.

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