Nursing Elites

1. Which of these findings should the nurse report immediately after a client has a liver biopsy?

• A. Temperature of 99.5 degrees F (37.5 degrees C)
• B. Blood pressure of 108/70
• C. Pulse oximetry reading of 96%
• D. Severe abdominal pain

Correct answer: D

Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.

2. A client is prescribed an inhaled corticosteroid for asthma management. Which instruction should the nurse provide to the client regarding the use of this medication?

• A. Rinse your mouth after using the inhaler
• B. Hold your breath for 5 seconds after inhaling the medication
• C. Use the inhaler during an acute asthma attack
• D. Take the medication only when symptoms occur

Correct answer: A

Rationale: The correct instruction for a client using an inhaled corticosteroid for asthma management is to rinse the mouth after using the inhaler. This helps prevent oral thrush, a common side effect of corticosteroid inhalers. Holding the breath for 5 seconds after inhaling the medication (Choice B) is not necessary for corticosteroid inhalers. Using the inhaler during an acute asthma attack (Choice C) is not the purpose of corticosteroids, which are used for long-term asthma management. Taking the medication only when symptoms occur (Choice D) is not correct as corticosteroids are typically used regularly to control asthma symptoms.

3. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?

• A. A 17-year-old client with schizophrenia who is pacing the hallways
• B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
• C. A 16-year-old client with depression who refuses to eat meals
• D. A 15-year-old client with anxiety who is quietly reading in a corner

Correct answer: B

Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.

4. The nurse is caring for a client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD?

• A. Administering narcotics for pain relief
• B. Encouraging the client to increase fluid intake
• C. Applying oxygen therapy at a high flow rate
• D. Assisting the client with deep breathing exercises

Correct answer: C

Rationale: The correct answer is C: Applying oxygen therapy at a high flow rate. In clients with COPD, high levels of supplemental oxygen can suppress the hypoxic drive to breathe, leading to carbon dioxide retention and respiratory depression. Oxygen therapy must be administered cautiously to prevent worsening respiratory status. Administering narcotics for pain relief (Choice A) can be necessary but should be done judiciously. Encouraging fluid intake (Choice B) and assisting with deep breathing exercises (Choice D) are generally beneficial interventions for clients with COPD and should not require the same level of caution as high-flow oxygen therapy.

5. A client is newly diagnosed with a duodenal ulcer. What information should the nurse provide during medication teaching?

• A. Take antacids regularly to manage symptoms.
• B. Avoid spicy foods and alcohol.
• C. Ensure proper administration of antibiotics.
• D. Stop all food intake until symptoms subside.

Correct answer: B

Rationale: The correct answer is B. Clients with duodenal ulcers should avoid spicy foods and alcohol as they can exacerbate symptoms and delay healing. Choice A is incorrect because while antacids may help with symptoms, they are not the primary focus of medication teaching for duodenal ulcers. Choice C is not directly related to medication teaching for duodenal ulcers unless antibiotics are specifically prescribed. Choice D is incorrect as stopping all food intake is not recommended and can lead to other complications.

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