Nursing Elites

1. A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the nurse include in the teaching?

• A. Inhale the medication deeply for 3-5 seconds
• B. Exhale forcefully before inhaling
• C. Shake the MDI vigorously before use
• D. Hold the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth

Correct answer: A

Rationale: Corrected Rationale: Inhaling the medication deeply for 3-5 seconds and holding the breath for 10 seconds after inhalation ensures effective medication delivery to the lungs. Choice A is the correct instruction for the use of a metered-dose inhaler (MDI). Choice B, exhaling forcefully before inhaling, is incorrect as it can lead to decreased medication delivery. Choice C, shaking the MDI vigorously before use, is also incorrect as excessive shaking can cause the medication to clump. Choice D, holding the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth, is not recommended as it may lead to improper inhalation technique.

2. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?

• A. Restrict protein intake to less than 40 g/day
• B. Initiate seizure precautions for the client
• C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
• D. Encourage the client to ambulate twice per day

Correct answer: B

Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.

3. A nurse is caring for a client with a history of hypertension. Which of the following should the nurse monitor?

• A. Fluid intake
• B. Blood pressure
• C. Serum potassium levels
• D. Weight

Correct answer: B

Rationale: The correct answer is B: Blood pressure. When caring for a client with a history of hypertension, monitoring blood pressure is crucial as it allows the nurse to assess the effectiveness of management and adjust treatment if necessary. Monitoring fluid intake (Choice A) is important for conditions like heart failure, but in hypertension, the focus is primarily on blood pressure. Monitoring serum potassium levels (Choice C) is relevant in clients taking certain medications like diuretics, and weight (Choice D) is important for overall health assessment but is not the primary parameter to monitor in hypertension.

4. During a skin assessment on a client with risk factors for skin cancer, a nurse should understand that a suspicious lesion is:

• A. Scaly and red
• B. Asymmetric with variegated coloring
• C. Firm and rubbery
• D. Brown with a wart-like texture

Correct answer: B

Rationale: The correct answer is B: Asymmetric with variegated coloring. An asymmetric lesion with variegated coloring, meaning different shades of color within the same lesion, is characteristic of melanoma, a type of skin cancer. This type of lesion should raise suspicions and prompt further evaluation. Choices A, C, and D do not typically represent characteristics of suspicious skin lesions associated with skin cancer. Lesions that are scaly and red (Choice A) may indicate other skin conditions like eczema or psoriasis. Firm and rubbery lesions (Choice C) are more suggestive of benign skin growths like dermatofibromas. Lesions that are brown with a wart-like texture (Choice D) are often indicative of seborrheic keratosis, a benign growth, rather than a suspicious lesion related to skin cancer.

5. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client has a productive cough and is started on airborne precautions. Which of the following interventions should the nurse implement?

• A. Wear an N95 respirator mask when caring for the client.
• B. Place the client in a semi-private room.
• C. Have the client wear a surgical mask during meals.
• D. Use a negative pressure air filtration system.

Correct answer: A

Rationale: The correct answer is to wear an N95 respirator mask when caring for the client with TB. This is crucial to prevent the nurse from inhaling the airborne particles that spread the infection. Choice B is incorrect because placing the client in a semi-private room does not address the protection of the nurse. Choice C is incorrect as having the client wear a surgical mask during meals is not sufficient to protect the nurse during all interactions. Choice D is incorrect as using a negative pressure air filtration system is more applicable to airborne infection isolation rooms in healthcare settings and not a standard intervention for nurses caring for a single client with TB.

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