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. Which information is a priority for the RN to reinforce to an older client after intravenous pyelography?

• A. Eat a light diet for the remainder of the day
• B. Rest for the next 24 hours as the preparation and the test are tiring
• C. Drink at least 1 8-ounce glass of fluid every waking hour for the next 2 days
• D. Measure the urine output for the next day and promptly notify the healthcare provider if it decreases

Correct answer: D

Rationale: After intravenous pyelography, it is crucial for the client to measure urine output in the next day to monitor for any potential complications, such as kidney issues. Promptly notifying the healthcare provider in case of decreased urine output is essential for timely intervention. While rest and hydration are important post-procedure, monitoring urine output takes precedence due to its direct correlation with potential complications.

3. What instruction should the nurse include for a client prescribed nitroglycerin for a myocardial infarction?

• A. Take the medication only when experiencing severe chest pain.
• B. Store the medication in a dark container to protect it from light.
• C. Take the medication before engaging in physical activity that may trigger chest pain.
• D. Limit nitroglycerin use to no more than three doses in 15 minutes.

Correct answer: D

Rationale: The correct answer is D: 'Limit nitroglycerin use to no more than three doses in 15 minutes.' This instruction is crucial to prevent excessive use, which can lead to severe hypotension and other complications. Choice A is incorrect because nitroglycerin should also be used preventatively, not only during severe chest pain. Choice B is irrelevant and not a necessary instruction for nitroglycerin use. Choice C is incorrect as nitroglycerin is typically taken to prevent chest pain rather than waiting for an activity that may trigger it.

4. A client with diabetes mellitus reports feeling shaky, dizzy, and sweaty. The nurse checks the client's blood glucose level and it is 55 mg/dL. What is the nurse's next action?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Administer 15 grams of a fast-acting carbohydrate
• D. Recheck the blood glucose level in 15 minutes

Correct answer: C

Rationale: A blood glucose level of 55 mg/dL indicates hypoglycemia, which should be treated with a fast-acting carbohydrate to quickly raise the blood sugar. Administering 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, is the appropriate initial intervention for hypoglycemia. Giving a glucagon injection is reserved for severe cases or when the client is unconscious. Encouraging the client to eat a high-protein snack is not appropriate for treating acute hypoglycemia, as it is a slower-acting form of glucose. Rechecking the blood glucose level is important but should occur after providing immediate treatment to raise the blood sugar level.

5. The nurse prepares a discharge plan for an older adult client following cataract extraction. What instructions should the nurse provide?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Irrigate the conjunctiva with saline before applying ointment.
• D. Read without direct lighting for 6 weeks.

Correct answer: A

Rationale: The correct instruction for the nurse to provide after cataract extraction is to advise the client to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure, which should be minimized post-surgery to promote healing and prevent complications. Choices B, C, and D are incorrect because limiting sunlight exposure, irrigating the conjunctiva with saline, and reading without direct lighting are not primary instructions following cataract extraction.

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