Nursing Elites

1. A client presents to the emergency department with a severe exacerbation of asthma. The nurse notes that the client is using accessory muscles to breathe and has an oxygen saturation of 86%. Which intervention should the nurse implement first?

• A. Place the client in a high-Fowler's position
• B. Obtain a peak flow reading
• C. Administer a bronchodilator
• D. Administer oxygen therapy

Correct answer: D

Rationale: The first priority in an acute asthma exacerbation is to administer oxygen to improve the client's oxygen saturation. In this scenario, the client has a low oxygen saturation level of 86%, indicating hypoxemia, which can be life-threatening. Administering oxygen therapy will help improve oxygenation and support vital organ function. Once the oxygen levels are stabilized, further interventions such as bronchodilators can be implemented. Placing the client in a high-Fowler's position may also be beneficial, but ensuring adequate oxygenation takes precedence in this critical situation. Obtaining a peak flow reading is important for asthma management but is not the first intervention needed in a client with severe hypoxemia.

2. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths/minute. What action should the nurse implement?

• A. Remove the mask immediately
• B. Document the assessment data
• C. Increase the oxygen flow
• D. Increase the respiratory rate setting

Correct answer: B

Rationale: The correct answer is to document the assessment data. In a partial rebreather mask, it is normal for the oxygen reservoir bag not to deflate completely during inspiration. Additionally, a respiratory rate of 14 breaths/minute falls within the normal range. Therefore, these findings indicate that the mask is functioning as intended. Removing the mask immediately is unnecessary as there are no signs of distress. Increasing the oxygen flow or adjusting the respiratory rate setting is not warranted based on the assessment findings, as they are within normal parameters.

3. A client with a urinary tract infection is prescribed trimethoprim. What is the most important teaching point?

• A. Take the medication only when symptoms are severe.
• B. Take the medication until symptoms disappear.
• C. Report any pain or burning with urination.
• D. Take the full course of antibiotics, even if symptoms improve.

Correct answer: D

Rationale: The correct answer is D: 'Take the full course of antibiotics, even if symptoms improve.' It is crucial for clients to complete the full course of antibiotics as prescribed to ensure that the infection is fully eradicated and to prevent the development of antibiotic resistance. Choice A is incorrect because antibiotics should not be reserved for severe symptoms only; they should be taken as prescribed. Choice B is incorrect as stopping the medication once symptoms disappear may lead to a relapse of the infection. Choice C is important but not the most crucial teaching point when compared to completing the full course of antibiotics.

4. Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's care plan?

• A. Check platelet count
• B. Observe the color of urine
• C. Review liver function tests
• D. Monitor for bleeding

Correct answer: D

Rationale: Prasugrel is a platelet inhibitor, which increases the risk of bleeding. Monitoring for bleeding, particularly at the catheterization site and in other areas, is the most important assessment following administration of the drug. Checking platelet count and observing urine color are relevant but not as immediate. Reviewing liver function tests is not directly related to the adverse effects of prasugrel.

5. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?

• A. Had a cold and ear infection for the past two days
• B. Missed a dose of insulin
• C. Did not follow dietary restrictions
• D. Overexerted during exercise

Correct answer: A

Rationale: The correct answer is A. Infections, like a cold and ear infection, increase the body's metabolic needs and insulin resistance, making diabetic ketoacidosis (DKA) more likely. While missing insulin doses or not following dietary restrictions can trigger DKA, an illness is the most common precipitating factor in pediatric Type 1 diabetes. Option B is less likely as missing insulin can lead to hyperglycemia but might not be the immediate cause of ketoacidosis. Option C can contribute to DKA over time, but the acute trigger is usually an illness. Option D, overexertion during exercise, is less likely to cause DKA compared to an infection.

Similar Questions