Nursing Elites

1. A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?

• A. Take the medication with food to avoid stomach upset.
• B. Avoid exposure to sunlight while taking this medication.
• C. Report any numbness or tingling in extremities.
• D. Have liver function tests done regularly.

Correct answer: D

Rationale: Regular monitoring of liver function tests is crucial for clients taking isoniazid (INH) due to the potential risk of hepatotoxicity. Isoniazid can cause liver damage, and early detection through routine liver function tests can help prevent severe complications.

2. 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.

3. A client in the emergency department is being cared for by a nurse and has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. What is the nurse's priority intervention?

• A. Provide the client with supplemental oxygen at 5 L/min via facemask.
• B. Place the client in high-Fowler's position with their legs in a dependent position
• C. Give the client sublingual nitroglycerin
• D. Administer morphine sulfate IV

Correct answer: A

Rationale: In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation and reduce the workload on the heart. Providing supplemental oxygen at 5 L/min via facemask helps increase oxygen levels and alleviate respiratory distress. This intervention can help improve oxygen saturation, alleviate dyspnea, and support the client's respiratory function. Placing the client in a high-Fowler's position with legs dependent can also help with respiratory effort, but ensuring adequate oxygenation takes precedence. Sublingual nitroglycerin and IV morphine sulfate are commonly used interventions for cardiac-related conditions, but in this case, addressing oxygenation is the priority to prevent further deterioration.

4. A healthcare professional is assessing a client with rheumatoid arthritis. Which assessment finding is most characteristic of this disease?

• A. Asymmetrical joint involvement
• B. Heberden's nodes
• C. Morning stiffness lasting more than 30 minutes
• D. Pain that worsens with activity

Correct answer: C

Rationale: Morning stiffness lasting more than 30 minutes is a hallmark symptom of rheumatoid arthritis. This prolonged morning stiffness is typically a distinguishing feature of rheumatoid arthritis compared to other types of arthritis, making it the most characteristic assessment finding for this disease.

5. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

• A. Document findings.
• B. Administer O2 therapy.
• C. Position client in high-Fowler's position.
• D. Administer prescribed albuterol.

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

Similar Questions