Nursing Elites

1. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minute, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take?

• A. Administer an anxiolytic
• B. Obtain a 12-lead electrocardiogram
• C. Stop the albuterol administration and restart in 30 minutes
• D. Educate the client about the side effects of albuterol

Correct answer: D

Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.

2. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?

• A. Instruct the client to perform cough and deep breathing exercises
• B. Assess the client’s vital signs and respiratory effort
• C. Administer oxygen via nasal cannula according to the PNR protocol
• D. Document assessment findings in the client’s medical record

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.

3. A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. Which breakfast items should the nurse encourage the client to eat? (Select all that apply)

• A. Sausage patties and eggs
• B. Whole wheat toast and jam
• C. Bagels and cream cheese
• D. Blackberries and oatmeal

Correct answer: B

Rationale: The correct choices are whole wheat toast and jam (B) and blackberries and oatmeal (D). Whole wheat toast and blackberries are high in fiber, which can help lower cholesterol levels. Sausage patties and eggs (A) are high in saturated fats that can raise cholesterol levels. Bagels and cream cheese (C) are not as beneficial for cholesterol control compared to high-fiber options like whole wheat toast and blackberries.

4. An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client’s spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?

• A. Reassure the spouse that the client will be well cared for and provide information about the facility’s care practices.
• B. Inform the spouse that care will be adjusted based on the client’s condition and needs.
• C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
• D. Suggest that the spouse speak with other family members for reassurance.

Correct answer: A

Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility’s care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.

5. After a sudden loss of consciousness, a female client is taken to the ED, and initial assessment indicates that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that she was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan?

• A. Describe the importance of maintaining stable blood glucose levels.
• B. Encourage a balanced and nutritious diet.
• C. Reinforce the need to continue outpatient treatment.
• D. Educate on the risks of untreated anorexia nervosa.

Correct answer: C

Rationale: Continuing outpatient treatment is crucial for managing anorexia nervosa and preventing future complications. Reinforcing the need to continue outpatient treatment ensures ongoing support, monitoring, and therapy for the client's anorexia nervosa. Describing the importance of maintaining stable blood glucose levels (Choice A) is relevant but does not address the underlying eating disorder directly. Encouraging a balanced and nutritious diet (Choice B) is important; however, specific dietary recommendations should be tailored to the individual's condition by healthcare providers. Educating on the risks of untreated anorexia nervosa (Choice D) is informative but does not provide a direct actionable step for the client's immediate discharge plan, unlike the importance of continuing outpatient treatment.

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