Nursing Elites

1. A client is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?

• A. Antibiotic
• B. Beta-blocker
• C. Antiviral
• D. Beta2 agonist

Correct answer: D

Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.

2. When caring for a client who is on contact precautions, which of the following measures should the nurse include in the teaching?

• A. Remove the protective gown after leaving the client's room.
• B. Place the client in a room with negative pressure.
• C. Wear gloves when providing care to the client.
• D. Wear a mask when in the client's room.

Correct answer: C

Rationale: Contact precautions are used for clients with known or suspected infections that are spread by direct or indirect contact. The most important measure for healthcare workers when caring for a client on contact precautions is to wear gloves when providing care. This helps prevent the transmission of infectious agents between the client and the healthcare worker. Removing the protective gown after leaving the client's room, placing the client in a room with negative pressure, and wearing a mask when in the client's room are not specific to contact precautions and may not be necessary for all clients on contact precautions.

3. When administering digoxin 0.125 mg PO to an adult client, for which of the following findings should the nurse report to the provider?

• A. Potassium level 4.2 mEq/L.
• B. Apical pulse 58/min
• C. Digoxin level 1 ng/mL
• D. Constipation for 2 days

Correct answer: C

Rationale: Monitoring the digoxin level is crucial as it helps determine the drug's effectiveness and potential toxicity. A digoxin level of 1 ng/mL is within the therapeutic range. However, levels above this range can lead to toxicity, causing adverse effects like nausea, vomiting, visual disturbances, and dysrhythmias. Therefore, the nurse should report a digoxin level of 1 ng/mL to the provider for further evaluation and potential dose adjustment.

4. A healthcare provider is caring for a client following a thoracentesis. Which of the following manifestations should the healthcare provider NOT recognize as risks for complications?

• A. Dyspnea
• B. Localized bloody drainage on the dressing
• C. Fever
• D. Hypotension

Correct answer: B

Rationale: After a thoracentesis, some expected complications include dyspnea, fever, and hypotension. Localized bloody drainage on the dressing is a common and expected finding post-thoracentesis due to the procedure's nature of puncturing the chest wall. Therefore, the healthcare provider should not consider this finding as a risk for complications.

5. While caring for a client in a clinic, a healthcare professional learns that the client woke up not recognizing their partner, surroundings, has chills, and chest pain worsening upon inspiration. What should be the healthcare professional's priority action?

• A. Obtain baseline vital signs and oxygen saturation.
• B. Obtain a sputum culture.
• C. Obtain a complete history from the client.
• D. Provide a pneumococcal vaccine.

Correct answer: A

Rationale: The priority action for the healthcare professional is to obtain the client's baseline vital signs and oxygen saturation. This will provide essential information on the client's current physiological status and help guide further assessment and intervention. Assessing the vital signs and oxygen saturation can help identify any immediate concerns like hypoxia or sepsis, which require prompt attention. While obtaining a complete history and considering a pneumococcal vaccine may be important in the overall care of the client, assessing the vital signs and oxygen saturation takes precedence to address the client's immediate physiological needs.

Similar Questions