Nursing Elites

1. The nurse is providing care for a client with chronic obstructive pulmonary disease (COPD). Which intervention is most appropriate to include in the care plan?

• A. Instruct the client to use pursed-lip breathing
• B. Recommend a high-fat, low-carbohydrate diet
• C. Limit physical activity to prevent shortness of breath
• D. Encourage the client to drink large amounts of fluids

Correct answer: A

Rationale: The correct answer is A: Instruct the client to use pursed-lip breathing. Pursed-lip breathing helps improve ventilation and reduce shortness of breath in COPD clients. This technique involves inhaling slowly through the nose and exhaling through pursed lips. Choice B is incorrect because a high-fat, low-carbohydrate diet is not recommended for individuals with COPD as it can lead to weight gain and worsen respiratory function. Choice C is incorrect as limiting physical activity can lead to deconditioning and worsen COPD symptoms. Regular, moderate exercise is beneficial for individuals with COPD. Choice D is incorrect as excessive fluid intake can strain the heart in COPD clients. It is important to maintain adequate but not excessive fluid intake to prevent dehydration and maintain optimal lung function.

2. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

• A. Empty the urinary drainage bag
• B. Feed the client a snack
• C. Offer the client oral fluids
• D. Assess the breath sounds

Correct answer: A

Rationale: The correct additional action the nurse should instruct the UAP to take each time the immobilized elderly client with an indwelling urinary catheter is turned is to empty the urinary drainage bag. This action helps to prevent backflow of urine, reduces the risk of infection, and prevents bladder distention, which are crucial for the client's comfort and health. Choices B, C, and D are incorrect as they are not directly related to the care of a client with an indwelling urinary catheter. Feeding a snack, offering oral fluids, or assessing breath sounds are important aspects of care but not the immediate action needed when turning a client with an indwelling urinary catheter to prevent complications.

3. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?

• A. Provide additional light in the room to promote sensory stimulation
• B. Teach the client to turn his head from side to side for visual scanning
• C. Place a clock and calendar in the room to improve orientation
• D. Use hand and arm gestures to improve communication and comprehension

Correct answer: B

Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.

4. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)

• A. Take out dentures and place them in a labeled cup
• B. Apply a body shroud
• C. Place a small pillow under the head
• D. Gently close the eyes

Correct answer: A

Rationale: The correct interventions for the nurse to prepare the body before the family enters the room include taking out dentures and placing them in a labeled cup. This is essential to ensure the dignity of the deceased and maintain their appearance. Applying a body shroud is not typically done before the family views the body, as it may be more appropriate during preparation for transportation to the funeral home. Placing a small pillow under the head and gently closing the eyes are actions that can be comforting but are not essential preparations for the family viewing.

5. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client’s right leg?

• A. Dorsiflexes the right foot and left foot on command
• B. A 3 by 5 cm ecchymosis area on the right calf
• C. Right calf is 3 cm larger in circumference than the left calf
• D. Bilateral lower extremities have 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant difference in calf circumference between the legs is a classic sign of DVT. This is due to the obstruction of blood flow in the deep veins of the leg, leading to swelling in the affected limb. Choices A, B, and D are not typical findings of DVT. Choice A describes a neurological response, choice B indicates a bruise on the right calf, and choice D describes pitting edema in both lower extremities, which are not specific signs of DVT.

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