Nursing Elites

1. The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?

• A. Use a heating pad on the legs
• B. Wear compression stockings
• C. Massage the legs daily
• D. Elevate legs for 10 minutes every hour

Correct answer: B

Rationale: The correct recommendation for a client with chronic venous insufficiency to prevent complications is to wear compression stockings. Compression stockings help improve venous circulation and prevent the worsening of symptoms. While elevating the legs is also beneficial, the priority intervention in preventing complications is wearing compression stockings. Using a heating pad on the legs can actually worsen the condition by dilating blood vessels, and massaging the legs daily can potentially damage fragile skin in clients with chronic venous insufficiency.

2. A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?

• A. Instruct the client to drink clear fluids and avoid solid foods.
• B. Administer antidiarrheal medication as prescribed.
• C. Encourage a high-fiber diet and regular physical activity.
• D. Restrict fluid intake and monitor electrolytes.

Correct answer: C

Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.

3. A client with a chest tube following a pneumothorax is complaining of increased shortness of breath. What is the nurse's first action?

• A. Check for kinks in the chest tube tubing.
• B. Assess the client's lung sounds.
• C. Elevate the head of the bed to 30 degrees.
• D. Prepare for chest tube replacement.

Correct answer: C

Rationale: The correct first action for a client with a chest tube experiencing increased shortness of breath is to elevate the head of the bed to 30 degrees. This position promotes lung expansion, improves oxygenation, and can help relieve shortness of breath. Checking for kinks in the chest tube tubing would be important but not the first action in this situation. Assessing the client's lung sounds is also important but not the initial priority. Preparing for chest tube replacement is not indicated based solely on the client's complaint of increased shortness of breath.

4. A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

• A. Cover the areas with dry sterile dressings
• B. Assess for dyspnea or stridor
• C. Initiate intravenous therapy
• D. Administer pain medication

Correct answer: B

Rationale: Assessing for dyspnea or stridor is crucial as these are signs of airway compromise, which is a priority concern in burns involving the face. Burns on the face can lead to airway swelling or compromise due to airway proximity, making respiratory assessment the top priority. Covering the areas with dry sterile dressings, initiating intravenous therapy, and administering pain medication are important interventions but assessing for airway issues takes precedence in this situation.

5. The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?

• A. Breath sounds are audible bilaterally
• B. Mist is visible in the T-piece
• C. Pulse oximetry of 88
• D. Client is unable to verbalize

Correct answer: C

Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.

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