Nursing Elites

1. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickening mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

• A. Increase the daily intake of oral fluids to liquefy secretions
• B. Avoid crowded enclosed areas to reduce pathogen exposure
• C. Call the clinic if undesirable side effects of medications occur
• D. Teach anxiety reduction methods for feelings of suffocation

Correct answer: A

Rationale: Increasing fluid intake is crucial as it helps to thin mucus secretions, making them easier to expectorate. This can alleviate the client's symptoms of shortness of breath and productive cough. Option B is not the most important action in this scenario, as it does not directly address the client's respiratory distress. Option C, while important, focuses on medication side effects rather than addressing the immediate breathing difficulties. Option D, teaching anxiety reduction methods, is not the priority when the client's main concern is respiratory distress.

2. The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?

• A. Breathe deeply, followed by swallowing.
• B. Breathe deeply, followed by spitting into a cup.
• C. Breathe deeply, followed by coughing up the sputum.
• D. Breathe deeply, followed by clearing the throat.

Correct answer: C

Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.

3. A client with hyperkalemia is being treated in the emergency department. Which medication should the nurse prepare to administer?

• A. Potassium chloride
• B. Calcium gluconate
• C. Magnesium sulfate
• D. Sodium bicarbonate

Correct answer: B

Rationale: The correct answer is B, Calcium gluconate. In hyperkalemia, where potassium levels are elevated, calcium gluconate is administered to stabilize the myocardial cell membrane and protect the heart from potential arrhythmias. Potassium chloride (choice A) would worsen the condition by further increasing potassium levels. Magnesium sulfate (choice C) is not the primary treatment for hyperkalemia. Sodium bicarbonate (choice D) is used in metabolic acidosis, not specifically for hyperkalemia.

4. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child?

• A. Excessive growth
• B. Cognitive impairment
• C. Damage to the nervous system
• D. Damage to the urinary system

Correct answer: B

Rationale: The correct answer is B: Cognitive impairment. The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment. Excessive growth (Choice A) is not a common complication of hypothyroidism in infants. Damage to the nervous system (Choice C) and damage to the urinary system (Choice D) are not typically associated with untreated hypothyroidism in infants.

5. Which finding should the nurse report immediately for a client receiving a blood transfusion?

• A. Mild itching and rash
• B. Temperature increase of 1.5°F (0.8°C)
• C. Heart rate increase of 10 beats per minute
• D. Slight headache

Correct answer: B

Rationale: A temperature increase of 1.5°F (0.8°C) during a blood transfusion is a significant finding that can indicate a transfusion reaction, such as a febrile non-hemolytic reaction, which can progress to more severe reactions. It is crucial to report this immediately to the healthcare provider for further evaluation and intervention. Mild itching and rash (choice A) are common minor reactions to blood transfusions and can be managed appropriately without immediate concern. An increase in heart rate by 10 beats per minute (choice C) is within an acceptable range and may be a normal compensatory response to the transfusion. A slight headache (choice D) is a common complaint and is not typically associated with severe transfusion reactions; thus, it does not require immediate reporting compared to the temperature increase.

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