Nursing Elites

1. A client is vomiting. Which of the following actions should the nurse take first?

• A. Provide the client with an emesis basin
• B. Notify housekeeping
• C. Prevent the client from aspirating
• D. Administer an antiemetic to the client

Correct answer: C

Rationale: When a client is vomiting, the priority action for the nurse is to prevent the client from aspirating. Aspiration can lead to serious respiratory complications. Providing the client with an emesis basin can be helpful but preventing aspiration takes precedence. Notifying housekeeping and administering an antiemetic are secondary actions that can be addressed once the client's safety is ensured.

2. A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?

• A. Call the Rapid Response Team.
• B. Document and continue to monitor.
• C. Notify the primary care provider.
• D. Repeat blood pressure measurement in 15 minutes.

Correct answer: A

Rationale: In this scenario, the significant drop in blood pressure indicates a potential emergency situation. The correct action is to call the Rapid Response Team (RRT) to ensure prompt intervention and prevent further deterioration that could lead to respiratory or cardiac arrest. It is crucial to act swiftly in response to such a critical change in vital signs to provide the client with the necessary care and support.

3. When caring for an older adult client with a pulmonary infection, what action should the nurse take first?

• A. Encourage the client to increase fluid intake.
• B. Assess the client's level of consciousness.
• C. Raise the head of the bed to at least 45 degrees.
• D. Provide the client with humidified oxygen.

Correct answer: B

Rationale: Assessing the client's level of consciousness is the priority because it provides crucial information on the client's neurological status and response to the infection. Changes in consciousness can indicate deterioration or improvement in the client's condition, guiding further interventions and treatment.

4. A client in a clinic presents with an acute asthma exacerbation. Which of the following medications should reduce the symptoms?

• A. Cromolyn via a metered-dose inhaler
• B. Montelukast orally
• C. Budesonide via a dry-powder inhaler
• D. Albuterol via a jet nebulizer

Correct answer: D

Rationale: During an acute asthma exacerbation, the preferred medication for symptom relief is a short-acting beta-agonist like albuterol, typically delivered via a jet nebulizer for quick onset and efficacy. Cromolyn, montelukast, and budesonide are not as effective for immediate symptom relief in acute exacerbations and are more commonly used for prevention or long-term management of asthma symptoms.

5. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?

• A. Night sweats
• B. Low-grade fever
• C. Weight gain
• D. Blood in the sputum

Correct answer: C

Rationale:

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