Nursing Elites

1. What are the nursing interventions for a patient with COPD?

• A. Administer oxygen and provide breathing exercises
• B. Suction airway secretions and encourage coughing
• C. Administer bronchodilators and monitor oxygen saturation
• D. Restrict fluids and encourage mobility

Correct answer: A

Rationale: The correct answer is A: Administer oxygen and provide breathing exercises. These interventions are essential in managing COPD as they help improve lung function and oxygenation. Choice B is incorrect as suctioning airway secretions and encouraging coughing are not typically indicated for COPD patients. Choice C is incorrect as while administering bronchodilators is common in COPD treatment, monitoring oxygen saturation alone is not a comprehensive intervention. Choice D is incorrect as restricting fluids is not a standard intervention for COPD, and encouraging mobility, although beneficial, is not as directly related to managing COPD symptoms as administering oxygen and providing breathing exercises.

2. A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

• A. Apply oxygen at 10 L/min via face mask
• B. Position the client on their side
• C. Call for a Cesarean delivery
• D. Administer oxytocin

Correct answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency, and the priority nursing action is to improve placental perfusion. Positioning the client on their side, particularly the left side, can enhance blood flow to the placenta and fetus by reducing pressure on the vena cava and increasing cardiac output. Applying oxygen, although helpful, is not the initial priority in this situation. Calling for a Cesarean delivery is not warranted unless other interventions fail to correct the late decelerations. Administering oxytocin can worsen the condition by increasing uterine contractions, exacerbating fetal distress.

3. A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

• A. Ensure the injection produces a wheal on the skin
• B. Administer the injection in the client's thigh
• C. Use an intradermal needle for the injection
• D. Avoid touching the site after injection

Correct answer: A

Rationale: The correct answer is A: Ensure the injection produces a wheal on the skin. A wheal indicates that the PPD has been administered correctly, allowing for the proper interpretation of results. Administering the injection in the client's thigh (choice B) is not the recommended site for PPD administration; it should be administered intradermally. Using an 18-gauge needle (choice C) is unnecessary and not the standard practice for PPD administration as a smaller gauge needle is preferred for intradermal injections. Massaging the site after injection (choice D) can lead to inaccurate results by dispersing the solution, so it is important to avoid touching the site after the injection to prevent altering the test results.

4. A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin A1c of 6%
• B. Fasting blood glucose of 90 mg/dL
• C. Blood glucose of 200 mg/dL
• D. Blood glucose of 100 mg/dL

Correct answer: C

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.

5. A nurse is caring for a client with a chest tube post-surgery. What is the most important assessment?

• A. Ensure the chest tube is clamped periodically
• B. Check for air leaks and ensure proper chest tube function
• C. Encourage deep breathing and coughing every 2 hours
• D. Ensure the client is positioned in a high Fowler's position

Correct answer: B

Rationale: The correct answer is B: 'Check for air leaks and ensure proper chest tube function.' This is the most important assessment for a client with a chest tube post-surgery because it ensures that the chest tube is functioning properly. Checking for air leaks helps prevent complications such as pneumothorax or hemothorax. Choice A is incorrect because clamping the chest tube periodically can lead to serious complications and should not be done unless specifically ordered by a healthcare provider. Choice C is important for promoting lung expansion but is not the most critical assessment related to the chest tube. Choice D is also important for respiratory function but is not the priority when assessing a chest tube post-surgery.

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