Nursing Elites

1. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?

• A. Administer a prescribed sedative
• B. Encourage client to drink water
• C. Apply a high flow venturi mask
• D. Assist her to an upright position

Correct answer: D

Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.

2. A client is admitted to the emergency department with symptoms of arm numbness, chest pain, and nausea/vomiting. The examining healthcare provider believes that the client has experienced an acute myocardial infarction (AMI) within the past three hours and would like to initiate tissue plasminogen activator (tPA) therapy. Which client history findings contraindicate the use of tPA?

• A. Treats hypoglycemia with an oral hypoglycemic agent.
• B. Had a cerebrovascular hemorrhage 2 months ago.
• C. Current age 65, father died of MI at 55.
• D. Report of being intolerant of medication that contains aspirin.

Correct answer: B

Rationale: A history of cerebrovascular hemorrhage is a contraindication for tPA therapy due to the risk of bleeding. Choice A is incorrect because treating hypoglycemia with an oral hypoglycemic agent is not a contraindication for tPA therapy. Choice C is incorrect as age and family history of MI do not contraindicate the use of tPA. Choice D is incorrect as being intolerant of medication containing aspirin is not a contraindication for tPA therapy.

3. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?

• A. Check the blood glucose level
• B. Administer insulin immediately
• C. Offer a high-protein snack
• D. Place the client in a supine position

Correct answer: A

Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.

4. A client with hyperkalemia is being treated in the emergency department. Which medication should the nurse prepare to administer?

• A. Potassium chloride
• B. Calcium gluconate
• C. Magnesium sulfate
• D. Sodium bicarbonate

Correct answer: B

Rationale: The correct answer is B, Calcium gluconate. In hyperkalemia, where potassium levels are elevated, calcium gluconate is administered to stabilize the myocardial cell membrane and protect the heart from potential arrhythmias. Potassium chloride (choice A) would worsen the condition by further increasing potassium levels. Magnesium sulfate (choice C) is not the primary treatment for hyperkalemia. Sodium bicarbonate (choice D) is used in metabolic acidosis, not specifically for hyperkalemia.

5. The parents of a child who has had a myringotomy are instructed by the nurse to place the child in which position?

• A. Supine
• B. On the affected side
• C. On the unaffected side
• D. In Trendelenburg's position

Correct answer: B

Rationale: Placing the child on the affected side after a myringotomy facilitates ear drainage. This position helps prevent accumulation of fluids in the ear canal, aiding in the healing process. Placing the child in the supine position (Choice A) or on the unaffected side (Choice C) may not be as effective in promoting drainage. The Trendelenburg's position (Choice D) with the head lower than the body is used for conditions requiring increased venous return, not for post-myringotomy care.

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