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. Which instruction is most important for the client who receives a new prescription for risedronate sodium to treat osteoporosis?

• A. Remain upright for 30 minutes after taking the medication
• B. Increase intake of foods rich in vitamin D
• C. Begin a low-impact exercise routine
• D. Take the medication with a full glass of water

Correct answer: A

Rationale: The most important instruction for a client receiving risedronate sodium to treat osteoporosis is to remain upright for 30 minutes after taking the medication. Risedronate sodium can cause esophageal irritation, and staying upright helps prevent this side effect. While increasing vitamin D intake, starting a low-impact exercise routine, and taking the medication with a full glass of water are all beneficial for managing osteoporosis, the immediate need is to prevent esophageal irritation caused by risedronate sodium.

3. A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply)

• A. Encourage oral fluid intake of 3,000 ml/day
• B. Observe for evidence of hypokalemia
• C. Teach the client how to restrict dietary sodium
• D. Monitor PTT, PT, and INR lab values

Correct answer: B

Rationale: The correct interventions to include when a client with heart failure is being treated with diuretics for fluid volume excess are to observe for evidence of hypokalemia. Diuretics can lead to potassium loss, resulting in hypokalemia. Monitoring for this electrolyte imbalance is crucial. Encouraging oral fluid intake of 3,000 ml/day may exacerbate fluid volume excess in a client with heart failure. Teaching the client how to restrict dietary sodium is important in managing heart failure, but it is not directly related to the use of diuretics for fluid volume excess. Monitoring PTT, PT, and INR lab values is not typically associated with diuretic therapy for heart failure but rather with anticoagulant therapy.

4. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Pheochromocytoma is associated with severe hypertension due to excessive catecholamine release. Monitoring blood pressure frequently is the priority intervention to assess for hypertensive crises and prevent complications like stroke, heart attack, or organ damage. While recording urine output every hour, evaluating neurological status, and maintaining seizure precautions are important aspects of care, they are not the highest priority in a client with pheochromocytoma.

5. The client has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to include in this client’s plan of care?

• A. Interventions to decrease emotional stress
• B. Precautions about avoiding sunlight
• C. Strategies to increase omega-3 fatty acids in the diet
• D. Instruct about applying a corticosteroid cream

Correct answer: A

Rationale: The most important aspect to include in this client's plan of care is interventions to decrease emotional stress. Psoriasis, characterized by silvery scaling plaques on the skin, can be exacerbated by emotional stress. Managing stress is crucial in controlling the condition. Precautions about avoiding sunlight are important in psoriasis management, but emotional stress has a more significant impact. While omega-3 fatty acids may provide some benefits, stress management should take priority. Applying a corticosteroid cream may help with symptoms, but addressing emotional stress is crucial for long-term management of psoriasis.

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