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 client with a urinary tract infection is prescribed ciprofloxacin. What is the nurse's priority teaching?

• A. Take the medication with a full glass of water.
• B. Avoid direct sunlight while taking the medication.
• C. Take the medication with meals to prevent nausea.
• D. Discontinue the medication if you experience dizziness.

Correct answer: A

Rationale: The correct answer is A: 'Take the medication with a full glass of water.' It is crucial for the nurse to teach the client to take ciprofloxacin with a full glass of water to prevent crystalluria, a potential side effect of the medication. Choice B is incorrect because ciprofloxacin does not require avoiding direct sunlight. Choice C is incorrect as taking the medication with meals is not necessary to prevent nausea. Choice D is incorrect as dizziness is not a common reason to discontinue ciprofloxacin.

3. What assessment is most important for the nurse to perform for a client with dehydration receiving IV fluids?

• A. Monitor the client’s electrolyte levels.
• B. Check the client’s urine output hourly.
• C. Assess the client’s skin turgor regularly.
• D. Monitor the client’s blood pressure every 15 minutes.

Correct answer: A

Rationale: The correct answer is to monitor the client’s electrolyte levels. When a client is receiving IV fluids for dehydration, it is crucial to assess their electrolyte levels regularly. Dehydration can lead to imbalances in electrolytes, especially sodium and potassium, which are essential for maintaining fluid balance and proper organ function. Checking urine output (Choice B) is important but not as critical as monitoring electrolyte levels. Assessing skin turgor (Choice C) is an indirect method of assessing dehydration but does not provide specific information about electrolyte imbalances. Monitoring blood pressure (Choice D) is important but not the most critical assessment in this scenario as electrolyte imbalances can have a more direct impact on the client's condition.

4. A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?

• A. Monitor the client's ammonia levels.
• B. Monitor the client's blood glucose level.
• C. Monitor the client's potassium levels.
• D. Monitor the client's level of consciousness.

Correct answer: D

Rationale: The correct answer is to monitor the client's level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy. Monitoring the level of consciousness helps assess the effectiveness of lactulose therapy in improving the client's condition. Monitoring ammonia levels (choice A) is important, but assessing the client's response to therapy through their level of consciousness is more crucial. Blood glucose levels (choice B) and potassium levels (choice C) are not directly related to lactulose therapy for cirrhosis and hepatic encephalopathy.

5. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

• A. Heart rate of 122 bpm and respiratory rate of 28.
• B. Yellow sputum expectorated.
• C. Temperature of 100.5°F (38.1°C).
• D. Shortness of breath on exertion.

Correct answer: C

Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.

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