Nursing Elites

1. A client is experiencing acute bronchospasm. What is the nurse's priority intervention?

• A. Administer a nebulizer treatment of albuterol.
• B. Start an IV infusion of normal saline.
• C. Administer oxygen at 4L/min via nasal cannula.
• D. Position the client in a high Fowler's position.

Correct answer: A

Rationale: The correct answer is to administer a nebulizer treatment of albuterol. In acute bronchospasm, the priority intervention is to deliver a bronchodilator like albuterol to open the airways and improve breathing. Starting an IV infusion of normal saline (Choice B) may be necessary but not the priority in this situation. Administering oxygen at 4L/min via nasal cannula (Choice C) is important but not the first intervention for bronchospasm. Positioning the client in a high Fowler's position (Choice D) can help with breathing but is not the priority over administering a bronchodilator.

2. A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?

• A. Limit sodium intake to 2 grams per day.
• B. Choose fresh fruits and vegetables.
• C. Drink at least 8 glasses of water daily.
• D. Avoid processed foods and canned soups.

Correct answer: D

Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.

3. When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

• A. The client delivered a large baby
• B. She is a gravida 6, para 5
• C. The client had a cesarean delivery
• D. The client had a prolonged labor

Correct answer: B

Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.

4. An older client with type 1 diabetes arrives at the clinic with abdominal cramping, vomiting, lethargy, and confusion. What should the nurse implement first?

• A. Start an IV infusion of normal saline.
• B. Obtain a serum potassium level.
• C. Administer the client's usual dose of insulin.
• D. Assess the pupillary response to light.

Correct answer: A

Rationale: The correct answer is A: Start an IV infusion of normal saline. The client is showing signs of dehydration, such as abdominal cramping, vomiting, lethargy, and confusion, which can be exacerbated by hyperglycemia. Rehydration is the initial priority to address the fluid imbalance. Option B, obtaining a serum potassium level, though important in the management of diabetes, is not the immediate priority over rehydration. Option C, administering the client's usual dose of insulin, should only be done after addressing the dehydration and confirming the client's blood glucose levels. Option D, assessing the pupillary response to light, is not the most urgent intervention needed in this situation compared to rehydration to correct fluid imbalance.

5. A client tells the nurse, 'I have something very important to tell you if you promise not to tell.' The best response by the nurse is

• A. I must document and report any information.
• B. I can't make such a promise.
• C. That depends on what you tell me.
• D. I must report everything to the treatment team.

Correct answer: B

Rationale: The correct answer is B because the nurse cannot promise confidentiality in this context. It is essential to prioritize the safety and well-being of the client and others. Certain information, such as harm to oneself or others, must be reported to ensure appropriate interventions are taken. Choice A is incorrect because while documentation is important, confidentiality cannot be guaranteed in this situation. Choice C is incorrect as the nurse should not make promises that may conflict with their professional responsibilities. Choice D is incorrect as reporting everything to the treatment team without discretion may breach client confidentiality.

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