Nursing Elites

1. A client with emphysema reports shortness of breath. What is the nurse's priority action?

• A. Administer oxygen therapy.
• B. Assess the client’s respiratory rate and effort.
• C. Prepare the client for intubation.
• D. Increase the client's oxygen flow rate.

Correct answer: B

Rationale: Shortness of breath in a client with emphysema may indicate respiratory distress. Assessing the client’s respiratory rate and effort is the first priority to determine the severity of the distress and guide appropriate interventions. Administering oxygen therapy (Choice A) could be necessary, but assessing the client first is crucial to tailor the intervention. Intubation (Choice C) is an invasive procedure that is not the initial priority. Increasing oxygen flow rate (Choice D) should only be done after a thorough assessment to avoid potential harm.

2. A male client admitted for schizophrenia is noted to be diaphoretic and pacing the hallway. What is the most important intervention?

• A. Take the client's temperature and blood pressure.
• B. Encourage the client to rest.
• C. Plan an activity involving physical exercise.
• D. Carefully observe the client throughout the shift.

Correct answer: D

Rationale: In this scenario, the most important intervention for a male client with schizophrenia who is diaphoretic and pacing the hallway is to carefully observe the client throughout the shift. Diaphoresis and pacing can be indicators of agitation or distress in clients with schizophrenia. Careful observation is crucial to monitor the client's safety, assess for any potential escalation of symptoms, and provide timely intervention if needed. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for safety and observation. Encouraging the client to rest (Choice B) may not be effective if the client is agitated. Planning an activity involving physical exercise (Choice C) could potentially exacerbate the situation rather than addressing the immediate need for observation and safety.

3. A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?

• A. Prothrombin time (PT)
• B. International normalized ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Platelet count

Correct answer: C

Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.

4. A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?

• A. Encourage the client to increase physical activity.
• B. Encourage the client to take rest breaks during activities.
• C. Administer a stimulant medication to reduce fatigue.
• D. Advise the client to use energy conservation techniques.

Correct answer: D

Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.

5. A client with type 1 diabetes mellitus is admitted to the emergency department with confusion, sweating, and a blood sugar level of 45 mg/dL. What is the nurse's priority action?

• A. Administer 50% dextrose IV push
• B. Provide a carbohydrate snack
• C. Check the client's urine for ketones
• D. Start an insulin drip

Correct answer: A

Rationale: A blood sugar level of 45 mg/dL indicates severe hypoglycemia, which can lead to life-threatening complications if not treated immediately. The priority is to administer IV dextrose to rapidly increase the blood sugar level. Administering 50% dextrose IV push will provide a quick source of glucose to raise the blood sugar. Providing a carbohydrate snack is not the immediate priority in this critical situation. Checking the client's urine for ketones is important in diabetic ketoacidosis, not for hypoglycemia. Starting an insulin drip would further lower the blood sugar and worsen the client's condition.

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