Nursing Elites

1. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?

• A. Administer a bronchodilator
• B. Obtain a peak flow reading
• C. Provide supplemental oxygen
• D. Assess the client's respiratory rate

Correct answer: A

Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.

2. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?

• A. Fluid volume deficit
• B. Altered nutrition: less than body requirements
• C. Anxiety related to new situational crisis
• D. Activity intolerance related to fatigue

Correct answer: A

Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.

3. When reviewing a client’s fluid and electrolyte status, what should the nurse report to the provider?

• A. Potassium 5.4
• B. Sodium 140
• C. Calcium 8.6
• D. Magnesium 2.0

Correct answer: A

Rationale: The correct answer is A: 'Potassium 5.4'. A potassium level of 5.4 is elevated (normal range is typically 3.5-5.0 mEq/L) and may indicate hyperkalemia, which can have serious cardiac implications. Elevated potassium levels can lead to life-threatening arrhythmias, so immediate reporting and intervention are necessary. Choice B, 'Sodium 140', falls within the normal range (135-145 mEq/L) and does not require immediate reporting. Choice C, 'Calcium 8.6', falls within the normal range (8.5-10.5 mg/dL) and is not an immediate concern. Choice D, 'Magnesium 2.0', is within the normal range (1.5-2.5 mEq/L) and does not need urgent reporting. Therefore, the nurse should prioritize reporting the elevated potassium level as it poses the most immediate risk.

4. A client is being taught how to care for their tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy site with hydrogen peroxide daily.
• C. Change the tracheostomy tube weekly.
• D. Apply ointment around the tracheostomy site.

Correct answer: A

Rationale: The correct instruction is to use tracheostomy covers when outdoors. Tracheostomy covers serve to protect the airway from environmental contaminants, reducing the risk of infection. Choice B is incorrect because hydrogen peroxide can be irritating to the skin and is not recommended for cleaning the tracheostomy site. Choice C is incorrect as tracheostomy tubes should not be routinely changed weekly unless there is a specific medical indication. Changing it without a need can introduce infection or damage the stoma. Choice D is incorrect as applying ointment around the tracheostomy site can lead to occlusion of the stoma and interfere with breathing.

5. When performing nasotracheal suctioning on a client with a respiratory infection, what technique should be used?

• A. Apply intermittent suction when withdrawing the catheter.
• B. Apply continuous suction during insertion of the catheter.
• C. Apply suction only during insertion of the catheter.
• D. Insert the catheter while the client is exhaling.

Correct answer: A

Rationale: The correct technique for nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps prevent damage to the mucosa and is the recommended approach. Continuous suction during insertion (choice B) can cause trauma to the airway lining. Applying suction only during insertion (choice C) is not sufficient for effective removal of secretions. Inserting the catheter while the client is exhaling (choice D) does not follow the standard procedure for nasotracheal suctioning.

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