Nursing Elites

1. 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: Nausea

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.

2. A client takes atorvastatin (Lipitor), with laboratory results showing a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

• A. Ask if the client eats grapefruit.
• B. Assess the client for dehydration.
• C. Facilitate admission to the hospital.
• D. Obtain a random urinalysis.

Correct answer: A

Rationale: There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. The client has elevated renal laboratory results, indicating kidney involvement. The nurse should ask if the client consumes grapefruit or grapefruit juice. While dehydration can elevate BUN, the increase in creatinine is more specific for kidney injury.

3. A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?

• A. I will reduce my sodium intake to help control my blood pressure.
• B. I need to start walking at least 30 minutes most days of the week.
• C. I can continue drinking alcohol as long as it is not in excess.
• D. I will check my blood pressure regularly at home.

Correct answer: C

Rationale: In hypertension management, it is crucial for clients to limit or avoid alcohol consumption, not just refrain from excess. Alcohol can raise blood pressure and interfere with the effectiveness of antihypertensive medications, making it a key lifestyle modification for individuals with hypertension.

4. The client is prescribed a long-acting beta2 agonist and expresses concerns about the cost, stating they only use the inhaler during asthma attacks. How should the nurse respond?

• A. Explain the importance of using the inhaler daily to prevent asthma attacks.
• B. Suggest identifying community services to help with the cost and encourage daily use of the inhaler.
• C. Explore the client's fears regarding breathlessness.
• D. Emphasize the necessity of using this inhaler daily and discuss potential community services for financial assistance.

Correct answer: B

Rationale: The correct response should address the client's concern about the cost of using the inhaler daily. While emphasizing the importance of daily use is crucial, it is also essential to acknowledge and offer support for the financial burden. Identifying community resources can help the client access affordable medications. Exploring fears related to breathlessness does not directly address the client's financial concerns.

5. A client is being admitted to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse’s priority?

• A. Bowel sounds
• B. Surgical dressing
• C. Temperature
• D. Oxygen saturation

Correct answer: Oxygen saturation

Rationale: The priority assessment for a client being admitted to the surgical unit following a cholecystectomy is oxygen saturation. Monitoring oxygen saturation is crucial to ensure adequate oxygenation and ventilation, especially after surgery. Hypoxia can have serious consequences and needs to be promptly addressed. While assessing bowel sounds, surgical dressing, and temperature are important, oxygen saturation takes precedence in this situation.

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