Nursing Elites

1. A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?

• A. Administer an antihypertensive medication as prescribed.
• B. Monitor the client's urine output.
• C. Administer oxygen therapy as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: D

Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.

2. When planning care for a 10-year-old child with pneumonia receiving oxygen at 5l/min per nasal cannula, what principle of oxygen administration should the nurse consider?

• A. Avoid administration of oxygen at high levels for extended periods.
• B. Increase oxygen flow rate if the child is still tachypneic.
• C. Reduce oxygen levels gradually after symptoms improve.
• D. Humidify the oxygen to prevent drying of mucous membranes.

Correct answer: A

Rationale: The correct principle of oxygen administration to consider is to avoid administering oxygen at high levels for extended periods. High levels of oxygen for prolonged periods can lead to oxygen toxicity, especially in pediatric patients. Increasing the oxygen flow rate based on tachypnea may not be necessary and can potentially lead to oxygen toxicity. Gradually reducing oxygen levels after symptoms improve may compromise the child's oxygenation. While humidifying oxygen is important to prevent drying of mucous membranes, the primary concern in this case is to avoid high oxygen levels for an extended duration to prevent oxygen toxicity.

3. A client with chronic kidney disease (CKD) is scheduled for a hemodialysis session. Which laboratory value should the nurse report to the healthcare provider before the procedure?

• A. Serum potassium of 5.5 mEq/L
• B. Blood urea nitrogen (BUN) of 40 mg/dl
• C. Serum potassium of 6.0 mEq/L
• D. Serum creatinine of 2.5 mg/dl

Correct answer: C

Rationale: A serum potassium level of 6.0 mEq/L is dangerously high for a client with chronic kidney disease (CKD) scheduled for hemodialysis. High potassium levels can lead to cardiac complications such as arrhythmias. Therefore, it is crucial to report this value to the healthcare provider before the procedure to prevent any potential serious complications. Choices A, B, and D are not as critical in the context of preparing for a hemodialysis session. Serum potassium levels above 6.0 mEq/L require immediate attention to ensure patient safety.

4. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

• A. Institute coughing and deep breathing protocols.
• B. Administer oxygen via nasal cannula.
• C. Prepare for intubation and mechanical ventilation.
• D. Increase IV fluids to improve hydration.

Correct answer: A

Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.

5. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?

• A. Increase intake of potassium-rich foods.
• B. Report increased bruising or bleeding.
• C. Stop medication if a cough develops.
• D. Limit intake of leafy green vegetables.

Correct answer: B

Rationale: The correct instruction for the nurse to include in the medication teaching plan is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which lowers platelet count and increases the risk of bruising and bleeding. Choice A is incorrect because while ACE inhibitors may cause potassium levels to increase, the instruction should not be to increase intake of potassium-rich foods without healthcare provider guidance. Choice C is incorrect because a cough is a common side effect of ACE inhibitors due to bradykinin accumulation, and stopping the medication abruptly is not recommended without consulting the healthcare provider. Choice D is incorrect because there is no need to limit intake of leafy green vegetables specifically with ACE inhibitors; however, consistent intake of vitamin K-rich foods is recommended to maintain a stable INR for clients taking anticoagulants.

Similar Questions