Nursing Elites

1. A nurse is providing teaching to a client who has a new prescription for albuterol. Which of the following client statements indicates an understanding of the teaching?

• A. I will use this medication to prevent an asthma attack.
• B. I will use this medication for shortness of breath during an asthma attack.
• C. I will take this medication with my daily vitamins.
• D. I will take this medication at bedtime to prevent an asthma attack.

Correct answer: B

Rationale: The correct answer is B because albuterol is used to treat shortness of breath during an asthma attack. Choice A is incorrect as albuterol is a rescue medication used during an asthma attack, not for prevention. Choice C is incorrect as albuterol should not be taken with daily vitamins. Choice D is incorrect as albuterol is not typically taken at bedtime for asthma prevention.

2. A nurse overhears two assistive personnel (AP) discussing a client in an elevator. What action should the nurse take?

• A. Contact the client's family about the incident.
• B. Notify the client's provider about the incident.
• C. File a complaint with the facility's ethics committee.
• D. Report the incident to the AP's charge nurse.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to report the incident to the AP's charge nurse. This is important because discussing a client's information violates confidentiality policies. Contacting the client's family (Choice A) is not appropriate as it may breach confidentiality further. Notifying the client's provider (Choice B) is not the initial action to take in this situation, as addressing it within the facility should come first. Filing a complaint with the facility's ethics committee (Choice C) is not the immediate step and might not directly address the issue at hand.

3. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

• A. Position the client supine.
• B. Prepare an IV bolus of dextrose 5% in water.
• C. Administer methylergonovine IM.
• D. Administer calcium gluconate IV.

Correct answer: D

Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.

4. A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?

• A. Elevate the client's legs while in bed.
• B. Reposition the client every 2 hours.
• C. Maintain bed rest for the first 24 hours postoperatively.
• D. Ambulate the client on the first postoperative day.

Correct answer: D

Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.

5. A client has a new prescription for spironolactone. Which of the following instructions should the nurse include?

• A. Take this medication with a potassium supplement.
• B. Avoid foods that contain potassium.
• C. Limit your fluid intake while taking this medication.
• D. Take this medication on an empty stomach.

Correct answer: B

Rationale: The correct answer is B because spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium. Instructing the client to avoid foods high in potassium helps prevent hyperkalemia, a potential side effect of spironolactone. Choice A is incorrect because taking spironolactone with a potassium supplement can increase the risk of hyperkalemia. Choice C is not directly related to spironolactone use. Choice D is also incorrect as spironolactone does not need to be taken on an empty stomach.

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