Nursing Elites

1. A 14-year-old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent?

• A. Nervousness should disappear when hypoxia is relieved after several bronchodilator treatments
• B. Tremors result from the rapid dilation of the bronchioles and an increased heart rate
• C. A fast heart rate and jitteriness are side effects of the bronchodilator treatment containing albuterol
• D. Excessive coughing, which causes tachypnea and anxiety, result from the use of bronchodilators

Correct answer: C

Rationale: The correct answer is C because a fast heart rate and jitteriness are common side effects of bronchodilators like albuterol. Choice A is incorrect as nervousness is more likely a side effect of the medication than solely related to hypoxia. Choice B is incorrect as it provides a partial explanation focusing only on tremors and heart rate, not mentioning jitteriness. Choice D is incorrect because excessive coughing and tachypnea are not typically associated with bronchodilator use; instead, they may indicate inadequate relief or other issues.

2. The nurse is planning care for a 2-year-old child who is scheduled for an infusion of immune globulin for treatment of idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis has the highest priority for this child?

• A. Risk for infection
• B. Risk for injury
• C. Altered oral mucous membranes
• D. Risk for fluid volume deficit

Correct answer: A

Rationale: The correct answer is 'Risk for infection.' When caring for a child with ITP scheduled for immune globulin infusion, the highest priority is to prevent infection. This is crucial due to the risk of bleeding associated with ITP and the immunosuppression that can be caused by the condition and its treatment. The other options, such as 'Risk for injury,' 'Altered oral mucous membranes,' and 'Risk for fluid volume deficit,' are not as high a priority as preventing infection in this particular situation.

3. A client is receiving a low dose of dopamine (Intropin) IV for the treatment of hypotension. Which indicator reflects that the medication is having the desired effect?

• A. Increased heart rate
• B. Increased urinary output
• C. Increased blood pressure
• D. Increased respiratory rate

Correct answer: C

Rationale: Increased blood pressure is the desired effect of administering dopamine (Intropin) to treat hypotension. Dopamine acts by stimulating adrenergic receptors, leading to vasoconstriction and increased cardiac output. This results in an elevation of blood pressure. Choices A, B, and D are incorrect as they do not directly reflect the therapeutic action of dopamine in treating hypotension. Increased heart rate may indicate the body compensating for low blood pressure, increased urinary output is more related to kidney function, and increased respiratory rate is often seen in response to respiratory issues, not the action of dopamine on hypotension.

4. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

• A. The depth of tissue destruction is minor
• B. Pain is interrupted due to nerve compression
• C. The full thickness burn has destroyed the nerves
• D. Second-degree burns are not usually painful

Correct answer: C

Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.

5. A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action?

• A. Administer an IV of normal saline rapidly and NPH insulin subcutaneously.
• B. Administer a retention enema of Kayexalate.
• C. Add 40 mEq of KCL (potassium chloride) to the present IV solution.
• D. Administer a lidocaine bolus IV push.

Correct answer: B

Rationale: In acute renal failure with a high serum potassium level, the priority intervention is to lower potassium levels to prevent complications like cardiac arrhythmias. Administering a retention enema of Kayexalate is the correct action as it helps lower high potassium levels by exchanging sodium for potassium in the intestines. Options A, C, and D are incorrect. Administering normal saline rapidly and NPH insulin or adding more potassium to the IV solution can further increase potassium levels, worsening the condition. Lidocaine is not indicated for treating hyperkalemia.

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