Nursing Elites

1. A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

• A. This medication is given to treat infection.
• B. This medication is given to facilitate ventilation.
• C. This medication is given to decrease inflammation.
• D. This medication is given to reduce anxiety.

Correct answer: B

Rationale: Vecuronium is a neuromuscular blocking agent that is used to facilitate ventilation by inducing muscle paralysis, which can help improve oxygenation in patients with ARDS. It does not treat infection, decrease inflammation, or reduce anxiety. Understanding the purpose of vecuronium administration is crucial for providing safe and effective care to patients with respiratory distress.

2. A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?

• A. SaO2 95%
• B. Wheezing
• C. Retraction of sternal muscles
• D. Premature ventricular complexes (PVC's)

Correct answer: A

Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.

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. While reviewing the laboratory results of a group of clients, which infection should the nurse in a provider's office report?

• A. Herpes simplex
• B. Human papillomavirus
• C. Candidiasis
• D. Chlamydia

Correct answer: D

Rationale: Chlamydia is a sexually transmitted infection that requires notification and intervention due to its public health implications and potential complications if left untreated. Reporting Chlamydia is crucial to initiate appropriate treatment, prevent further spread of the infection, and provide necessary counseling to affected individuals. While other infections like herpes simplex, human papillomavirus, and candidiasis are also significant, Chlamydia is particularly important to report in this context.

5. 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.

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