Nursing Elites

1. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

• A. Initiating oxygen therapy
• B. Providing immediate rest for the client
• C. Positioning the client in high-Fowler's
• D. Administering a nebulized beta-adrenergic

Correct answer: D

Rationale: During an acute asthma exacerbation, the priority intervention is to administer a nebulized beta-adrenergic medication, such as albuterol, to help open the airways and improve breathing. This action helps address the underlying cause of the exacerbation. Oxygen therapy may be needed but is not the priority over administering the bronchodilator. Providing rest and positioning the client in high-Fowler's are important but come after administering the medication to address the immediate breathing difficulties.

2. A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?

• A. Severe dyspnea
• B. Nausea
• C. Decreased level of consciousness
• D. Headache

Correct answer: B

Rationale: In acute respiratory failure, the body is not getting enough oxygen, leading to hypoxia. Symptoms of hypoxia include severe dyspnea (A), decreased level of consciousness (C), and headache (D) due to inadequate oxygen supply to the brain. Nausea (B) is not a typical manifestation of acute respiratory failure and is not directly related to the lack of oxygen in the body. Therefore, the nurse should not monitor the client for nausea as a direct consequence of ARF.

3. A healthcare professional is interested in making interdisciplinary work a high priority. Which actions by the professional best demonstrate this skill? (Select ONE that does not apply)

• A. Consulting with other disciplines on client care
• B. Coordinating discharge planning for home safety
• C. Participating in comprehensive client rounding
• D. Sharing the care plans with other disciplines

Correct answer: B

Rationale: Interdisciplinary work in healthcare involves effective communication and collaboration between different disciplines for holistic client care. Consulting with other disciplines allows for sharing expertise, insights, and perspectives to enhance client outcomes. Participating in comprehensive client rounding involves a team-based approach to discuss and plan client care collectively. Sharing nursing care plans with other disciplines ensures that all team members are informed and can contribute to the client's overall well-being. Coordinating discharge planning is important but may not directly demonstrate interdisciplinary collaboration as the other actions do.

4. The provider requests the nurse to start an infusion of an inotropic agent on a client. How should the nurse explain the action of these drugs to the client and spouse?

• A. It constricts vessels, improving blood flow.
• B. It dilates vessels, which lessens the work of the heart.
• C. It increases the force of the heart's contractions.
• D. It slows the heart rate down for better filling.

Correct answer: C

Rationale: An inotropic agent is a medication that increases the force of the heart's contractions, which helps improve cardiac output. Choice A and B are incorrect as inotropic agents do not constrict or dilate vessels. Choice D is also incorrect as inotropic agents do not slow down the heart rate but rather enhance the heart's contractility.

5. A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)

• A. Administer prescribed albuterol (Ventolin) inhaler.
• B. Assess the client for tracheal deviation.
• C. Administer oxygen to maintain saturations greater than 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation indicates the use of accessory muscles and difficulty in moving air due to airway narrowing, supported by bilateral wheezing and decreased pulse oxygen saturation. This client needs immediate intervention as their asthma is not responding to the medication. Administering oxygen to maintain saturations above 94% is crucial to ensure adequate oxygenation. While administering a rescue inhaler could also be necessary, oxygen therapy takes priority in this situation.

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