Nursing Elites

1. A client with tuberculosis is starting combination drug therapy. Which of the following medications should the nurse NOT plan to administer?

• A. Rifampin
• B. Isoniazid
• C. Acyclovir
• D. Pyrazinamide

Correct answer: C

Rationale: Acyclovir is an antiviral medication used to treat herpes virus infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all commonly used in the treatment of tuberculosis. Therefore, the nurse should not plan to administer Acyclovir to a client with tuberculosis.

2. A client has a newly inserted chest drainage system with a water seal. Which of the following actions should be taken?

• A. Clamp the tube when the client is ambulating.
• B. Keep the collection device below the level of the client's chest.
• C. Carefully coil the tubes to prevent kinking.
• D. Position the client flat to avoid leaks in the tubing.

Correct answer: B

Rationale: Keeping the collection device below the level of the client's chest ensures proper drainage and prevents backflow of fluid into the patient's chest. This position allows gravity to assist in the drainage process. Clamping the tube when the client is ambulating can cause a buildup of pressure in the chest drainage system, potentially leading to complications. Carefully coiling the tubes is important to prevent obstructions and kinks that could impede the flow of drainage. Positioning the client flat may not be ideal as it could hinder proper drainage and increase the risk of leaks in the tubing.

3. What instruction should be included when teaching a client with asthma about using a metered-dose inhaler (MDI)?

• A. Shake the inhaler well before use.
• B. Inhale rapidly while administering the medication.
• C. Administer the medication while lying down.
• D. Hold the inhaler 2 inches away from the mouth while inhaling.

Correct answer: A

Rationale: Shaking the inhaler well before use ensures that the medication is properly mixed, allowing for an accurate dose with each administration. Inhaling slowly and deeply, not rapidly, helps the medication reach the lungs effectively. The medication should be administered while sitting or standing to facilitate proper lung expansion and airflow. Holding the inhaler 2 inches away from the mouth can lead to medication loss; it should be placed directly in the mouth or used with a spacer to optimize delivery to the airways.

4. A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

• A. Prevent aspiration.
• B. Ensure adequate nutrition.
• C. Promote oral hygiene.
• D. Relieve the client's pain.

Correct answer: A

Rationale: Preventing aspiration is the priority for a client with intermaxillary fixation following mandibular surgery. Aspiration can occur due to difficulty swallowing or improper positioning, posing a serious risk to the client's respiratory status. It is crucial for the nurse to ensure that the client's airway is clear and that they are positioned correctly to prevent any potential aspiration events.

5. A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?

• A. Administer oxygen at 2 liters per minute via nasal cannula.
• B. Assess the client's vital signs including oxygen saturation.
• C. Notify the Rapid Response Team immediately.
• D. Place the client in a high Fowler's position.

Correct answer: D

Rationale: Placing the client in a high Fowler's position is the best action in this situation as it helps to maximize lung expansion, improve breathing, and decrease the work of breathing. This position allows for better chest expansion, improving oxygenation and ventilation for the client in respiratory distress.

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