Nursing Elites

1. The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?

• A. To promote oxygenation by removing secretions.
• B. To reduce the amount of air trapped in the lungs.
• C. To increase the amount of carbon dioxide exhaled.
• D. To slow the respiratory rate and improve air exchange.

Correct answer: C

Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A) and reducing air trapping (B) can be associated benefits to some extent, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics. Slowing the respiratory rate (D) is not the primary purpose of pursed-lip breathing.

2. During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?

• A. Provide information about the hours and location of the chapel
• B. Document the statement in the client’s spiritual assessment
• C. Invite the client to a healing service for people of all religions
• D. Offer to contact a spiritual advisor of the client’s choice

Correct answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care. Providing information about the chapel's hours and location (choice A) may not align with the client's beliefs as an agnostic. Inviting the client to a healing service (choice C) assumes the client's interest in such activities, which may not be the case. Offering to contact a spiritual advisor (choice D) may not be necessary if the client did not express a desire for it.

3. A healthcare professional is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck. The client is alert but reports feeling faint. Which assessment will the healthcare professional perform first?

• A. Pulse characteristics
• B. Open airway
• C. Entrance and exit wounds
• D. Cervical spine injury

Correct answer: A

Rationale: When a person is struck by lightning, it can cause an electrical shock that may affect the heart rhythm. Therefore, assessing pulse characteristics is crucial as lightning can act as a natural defibrillator. Monitoring the pulse rate and regularity will help determine if there are any cardiac abnormalities that need immediate attention. Open airway, entrance and exit wounds, and cervical spine injury assessments are also important but assessing pulse characteristics takes precedence in this situation to address potential cardiac issues.

4. The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?

• A. Apply the restraints to ensure the client's safety.
• B. Reassess the client to determine if restraints are still necessary.
• C. Document the time the family departed and continue monitoring the client.
• D. Contact the healthcare provider for a new order.

Correct answer: B

Rationale: In this scenario, the nurse's initial action should be to reassess the client to determine if restraints are still necessary following their removal by the family. This reassessment is crucial to evaluate the client's current condition and the need for restraints before considering reapplication. By reassessing first, the nurse ensures that the client's safety is maintained while respecting their autonomy. While documentation and monitoring are important, reassessment takes priority to provide individualized and appropriate care to the client. Contacting the healthcare provider for a new order should occur after reassessment if restraints are deemed necessary.

5. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

• A. Perform cough and deep breathing exercises hourly.
• B. Turn from side to side in bed at least every 2 hours.
• C. Dorsiflex and plantarflex the feet 10 times each hour.
• D. Drink approximately 4 ounces of water every hour.

Correct answer: C

Rationale: The most crucial instruction for a client with limited mobility to prevent venous thrombosis is to perform dorsiflexion and plantarflexion of the feet 10 times each hour. These exercises help promote venous return, reducing the risk of thrombosis by preventing blood stasis in the lower extremities. While other measures like turning in bed and staying hydrated are beneficial, promoting venous return through foot exercises is the priority in preventing venous thrombosis in clients with limited mobility. Dorsiflexion and plantarflexion directly target the calf muscle pump, aiding in the circulation of blood back to the heart and preventing clot formation. The other options, such as cough and deep breathing exercises, turning in bed, and hydration, are important for overall health but do not directly address venous stasis and thrombosis prevention in the same way as foot exercises.

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