Nursing Elites

1. A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?

• A. "It might help if I tried sleeping only on my back."
• B. "I'll sleep better if I take a sleeping pill at night."
• C. "I'll get a humidifier to run at my bedside at night."
• D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."

Correct answer: D

Rationale:

2. A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

• A. Insert an IV line
• B. Count the respiratory rate
• C. Administer oxygen
• D. Prepare equipment for intubation

Correct answer: B

Rationale: When suspecting anaphylaxis, the priority intervention is to assess the client's respiratory status by counting the respiratory rate. Respiratory distress is a hallmark sign of anaphylaxis, and prompt recognition and management are crucial. Administering oxygen may be necessary, but assessing the respiratory rate takes precedence to determine the severity of the reaction and the need for immediate intervention. Inserting an IV line and preparing for intubation are important interventions in managing anaphylaxis but are secondary to ensuring adequate ventilation.

3. A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?

• A. Do you have a strong support system?
• B. What do you understand about your disease?
• C. Do you experience shortness of breath with basic activities?
• D. What medications are you prescribed to take each day?

Correct answer: C

Rationale: In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.

4. A client with diabetes is experiencing symptoms of hypoglycemia. What should the nurse administer first?

• A. 10 units of regular insulin subcutaneously
• B. 50 mL of 50% dextrose solution intravenously
• C. 1 mg of glucagon intramuscularly
• D. 15-20 grams of fast-acting carbohydrate orally

Correct answer: D

Rationale: The correct first intervention for a client experiencing hypoglycemia is administering 15-20 grams of fast-acting carbohydrate orally. If the client is conscious and able to swallow, providing quick-acting carbohydrates helps raise blood glucose levels rapidly and effectively. This approach is preferred over other options like administering insulin, dextrose solution intravenously, or glucagon, which are not the initial interventions for hypoglycemia.

5. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• A. Breathing so rapidly interferes with oxygenation.
• B. Maybe the client has respiratory distress syndrome.
• C. The blood clot interferes with perfusion in the lungs.
• D. The client needs immediate intubation & mechanical ventilation.

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

Similar Questions