Nursing Elites

1. A client presents to the emergency room with an acute asthma attack. What is the nurse's priority intervention?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen at 2 liters per nasal cannula.
• C. Perform chest physiotherapy.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as prescribed. During an acute asthma attack, the priority is to open the airways quickly to help the client breathe more easily. Oxygen may be needed but bronchodilators take precedence as they directly target bronchoconstriction. Chest physiotherapy is not indicated in the acute phase of asthma and may exacerbate the condition. While emotional support is important, addressing the airway obstruction takes precedence in this situation.

2. A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan?

• A. Experiences occasional heartburn after eating spicy food
• B. Consumes 10 or more drinks of alcohol every weekend
• C. Reports frequent use of NSAIDs
• D. Has a history of peptic ulcers

Correct answer: B

Rationale: Excessive alcohol consumption is a major risk factor for gastritis and should be prioritized in the teaching plan. While spicy foods and NSAIDs can contribute to gastritis, alcohol consumption is the most significant factor that needs immediate lifestyle changes to prevent worsening of gastritis symptoms. Peptic ulcers, although relevant, are not as directly linked to exacerbating gastritis symptoms as alcohol consumption.

3. A client with chronic obstructive pulmonary disease (COPD) is admitted with increasing shortness of breath. What is the nurse's priority action?

• A. Administer oxygen via nasal cannula.
• B. Reposition the client to improve breathing.
• C. Perform chest physiotherapy.
• D. Encourage the client to cough and deep breathe.

Correct answer: A

Rationale: The correct answer is A: Administer oxygen via nasal cannula. Oxygen therapy is the priority intervention for a client with COPD experiencing increasing shortness of breath. It helps improve oxygenation and relieve respiratory distress. Choice B is not the priority as oxygenation needs to be addressed first. Choice C, chest physiotherapy, may be beneficial but is not the immediate priority in this situation. Choice D, encouraging the client to cough and deep breathe, is not the priority intervention when oxygenation is compromised.

4. When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate the closest proximal pulse.
• B. Observe the color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.

5. 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.

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