Nursing Elites

1. A client with asthma is receiving albuterol (Proventil). The nurse should monitor the client for which of the following side effects?

• A. Hypoglycemia
• B. Hyperkalemia
• C. Tachycardia
• D. Hypotension

Correct answer: C

Rationale: The correct answer is C: Tachycardia. Albuterol can cause tachycardia as a side effect due to its stimulant effect on the heart. It acts as a beta-2 adrenergic agonist, leading to increased heart rate. Hypoglycemia (choice A) is not a common side effect of albuterol. Hyperkalemia (choice B) is also not typically associated with albuterol use. Hypotension (choice D) is less likely to occur as albuterol usually causes tachycardia rather than hypotension.

2. A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis?

• A. Low serum albumin
• B. High serum cholesterol
• C. Abnormally low white blood cell count
• D. Elevated creatinine phosphokinase (CPK)

Correct answer: D

Rationale: The correct answer is D: Elevated creatinine phosphokinase (CPK). Elevated CPK levels indicate muscle damage, including damage to the cardiac muscle, which aligns with the diagnosis of myocardial infarction. Choice A, low serum albumin, is not directly related to myocardial infarction. Choice B, high serum cholesterol, is more associated with conditions like atherosclerosis rather than acute myocardial infarction. Choice C, abnormally low white blood cell count, is typically not a lab value associated with myocardial infarction; instead, it could suggest other conditions like infections or bone marrow issues.

3. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: B

Rationale: The correct answer is B: secondary prevention. Secondary prevention involves identifying and addressing issues early to prevent further harm. In this scenario, the nurse is intervening by discussing domestic violence prevention with the client who is showing signs of facial bruising, aiming to prevent further harm even though the client has not disclosed being battered. Choice A (primary prevention) focuses on preventing the onset of a problem before it occurs, like educating about healthy relationships before violence happens. Choice C (tertiary prevention) involves managing and treating the effects of a problem that has already occurred, such as providing counseling to a domestic violence survivor. Choice D (health promotion) aims to enhance well-being and prevent health problems through educational and environmental interventions, which may include aspects of preventing domestic violence, but in this case, the nurse's direct intervention is more about early identification and prevention of harm, aligning it with secondary prevention.

4. A client is admitted for COPD. Which finding would require the nurse's immediate attention?

• A. Nausea and vomiting
• B. Restlessness and confusion
• C. Low-grade fever and cough
• D. Irritating cough and liquefied sputum

Correct answer: B

Rationale: Restlessness and confusion are signs of hypoxia and hypercapnia in a client with COPD, indicating that the client's condition may be deteriorating rapidly. Immediate attention is necessary to prevent further complications. Nausea and vomiting (Choice A) may be related to various factors but do not directly indicate respiratory distress. Low-grade fever and cough (Choice C) are common in COPD and may not require immediate intervention. Irritating cough and liquefied sputum (Choice D) are typical symptoms of COPD exacerbation but do not signal an immediate need for attention as restlessness and confusion.

5. The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach and phase the nurse manager should

• A. Discuss with the staff how to deal with any defensive behavior
• B. Explain to the unit staff why change is necessary
• C. Assist the staff during the acceptance of the new changes
• D. Clarify what the changes mean to the community and hospital

Correct answer: B

Rationale: The "unfreezing" phase involves preparing staff for change by explaining the necessity and benefits of the change, helping them to understand and accept it.

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