Nursing Elites

1. A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?

• A. Blow cool air from a hair dryer under the cast
• B. Twist the cast back and forth
• C. Shake powder into the cast
• D. Push a pencil under the cast edge

Correct answer: A

Rationale: The correct answer is A: 'Blow cool air from a hairdryer under the cast.' Blowing cool air can help relieve itching without damaging the cast or causing injury. Choice B, twisting the cast back and forth, can lead to discomfort, skin irritation, or even injury. Choice C, shaking powder into the cast, can create a mess, increase the risk of skin issues, and interfere with proper healing. Choice D, pushing a pencil under the cast edge, is dangerous as it can cause injury to the child's skin or the underlying tissues. Therefore, the safest and most effective option to relieve itching under the cast is to blow cool air from a hair dryer.

2. 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.

3. A client who is HIV positive and taking lamivudine (Epivir) calls the clinic to report a cough and fever. What action should the nurse implement?

• A. Advise the client to come to the clinic for an evaluation
• B. Advise the client to increase fluid intake
• C. Advise the client to take an over-the-counter cough suppressant
• D. Advise the client to rest and call if the fever persists

Correct answer: A

Rationale: The correct action for the nurse to implement in this situation is to advise the client to come to the clinic for an evaluation. Given the client's HIV-positive status and medication, it is crucial to assess the cough and fever promptly to identify the underlying cause. Increasing fluid intake (choice B) may be beneficial but does not address the need for evaluation. Taking an over-the-counter cough suppressant (choice C) may not be appropriate without knowing the cause of the symptoms. Advising the client to rest and call if the fever persists (choice D) delays the necessary evaluation and treatment.

4. Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?

• A. Complaints of an occipital headache
• B. A palpable dorsal pedis pulse bilaterally
• C. Complaints of shortness of breath on exertion
• D. A blood pressure of 160/90

Correct answer: C

Rationale: The correct answer is C, complaints of shortness of breath on exertion. This symptom is indicative of heart failure, a common cardiac complication of arterial hypertension. Shortness of breath on exertion is often due to the heart's inability to pump effectively, leading to fluid buildup in the lungs. Choices A, B, and D are incorrect because complaints of an occipital headache, a palpable dorsal pedis pulse bilaterally, and a blood pressure of 160/90 do not specifically indicate a cardiac complication in a client with arterial hypertension.

5. The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?

• A. Notify the healthcare provider of the laboratory results
• B. Decrease the rate of the IV infusion
• C. Stop the infusion
• D. Administer sodium polystyrene sulfonate (Kayexalate)

Correct answer: C

Rationale: The correct action for the nurse to implement first is to stop the infusion. Stopping the infusion is crucial to prevent further potassium from being administered, which can exacerbate the client's hyperkalemia. Notifying the healthcare provider of the laboratory results (Choice A) can be done after taking immediate action to stop the infusion. Decreasing the rate of the IV infusion (Choice B) may not be sufficient to address the high potassium level quickly. Administering sodium polystyrene sulfonate (Kayexalate) (Choice D) is not the initial action for managing hyperkalemia; stopping the potassium infusion takes precedence.

Similar Questions