Nursing Elites

1. A client is experiencing shortness of breath and wheezing. What is the nurse's first action?

• A. Administer bronchodilator medication
• B. Check the client's oxygen saturation
• C. Encourage the client to use pursed-lip breathing
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention to open the airways and relieve wheezing and shortness of breath. Bronchodilators work quickly to dilate the airways, making it easier for the client to breathe. Checking oxygen saturation is important but can be done after initiating bronchodilator therapy. Encouraging pursed-lip breathing and elevating the head of the bed can help improve breathing patterns but should follow the administration of the bronchodilator.

2. During the admission assessment of a 3-year-old with bacterial meningitis and hydrocephalus, which assessment finding is evidence of increased intracranial pressure (ICP)?

• A. Low blood pressure
• B. Increased respiratory rate
• C. Normal pupil reaction
• D. Sluggish and unequal pupillary responses

Correct answer: D

Rationale: Sluggish and unequal pupillary responses are indicative of increased intracranial pressure (ICP) in a child with bacterial meningitis and hydrocephalus. This finding suggests that the optic nerve is being compressed due to increased ICP, causing a delay in pupillary reactions. Such a delay is a critical sign of worsening ICP and necessitates immediate intervention. Low blood pressure and increased respiratory rate can occur in various conditions but are less specific to increased ICP than sluggish and unequal pupillary responses, which directly reflect neurological compromise.

3. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?

• A. Assess the client's bowel sounds
• B. Administer prescribed pain medication
• C. Encourage the client to sit upright
• D. Provide clear fluids to the client

Correct answer: B

Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.

4. A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?

• A. Trendelenburg
• B. Supine
• C. Prone
• D. Fowler's

Correct answer: D

Rationale: Fowler's position (head elevated at 45-60 degrees) improves oxygenation by expanding the lungs, making it the best position for clients with dyspnea. Supine or prone positions restrict lung expansion, and Trendelenburg position (head down) can exacerbate breathing difficulties by increasing pressure on the lungs and diaphragm.

5. A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?

• A. Obtain an analgesic prescription.
• B. Administer an IV fluid bolus.
• C. Administer PRN antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: The correct first intervention for a client with adrenal crisis and hypotension is to administer an IV fluid bolus. In adrenal crisis, the body is deficient in cortisol, leading to hypotension. Fluid resuscitation helps stabilize the blood pressure. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering a PRN antipyretic (Choice C) is not indicated as the client's vital signs do not suggest fever. Covering the client with a cooling blanket (Choice D) is not appropriate for addressing hypotension in adrenal crisis.

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