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. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?

• A. Apical heart rate
• B. IV site and fluids
• C. Pain scale
• D. Temperature

Correct answer: C

Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

3. An angry client screams at the emergency department triage nurse, “I’ve been waiting here for two hours! You and the staff are incompetent”. What is the best response for the nurse to make?

• A. The emergency department is very busy at this time.
• B. I’ll let you see the doctor next because you’ve waited so long.
• C. I’m doing the best I can for the sickest clients first.
• D. I understand you are frustrated with the wait time.

Correct answer: D

Rationale: Correct Answer: The best response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response demonstrates empathy and validates the client's feelings, helping to defuse the situation. Choice A is not the best response as it does not directly address the client's emotions or concerns. Choice B is inappropriate as it gives preferential treatment based on the client's behavior. Choice C, while true, does not acknowledge the client's frustration or offer empathy.

4. When taking a health history of a client admitted with acute pancreatitis, which client complaint should be expected?

• A. A low-grade fever and left lower abdominal pain
• B. Severe headache and sweating all the time
• C. Severe mid-epigastric pain after ingesting a heavy meal
• D. Dull, continuous, right lower quadrant pain and nausea

Correct answer: C

Rationale: The correct answer is C: 'Severe mid-epigastric pain after ingesting a heavy meal.' This symptom is characteristic of acute pancreatitis due to inflammation of the pancreas, which often presents with severe pain in the mid-epigastric region that may worsen after eating. Choices A, B, and D describe symptoms that are not typically associated with acute pancreatitis. A low-grade fever and left lower abdominal pain (Choice A) may be more indicative of other conditions like diverticulitis. Severe headache and sweating (Choice B) are commonly seen in conditions like migraines or infections. Dull, continuous, right lower quadrant pain and nausea (Choice D) could be suggestive of appendicitis rather than acute pancreatitis.

5. The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?

• A. Perform a complete neurological examination
• B. Measure the child’s head circumference
• C. Check the child’s blood glucose level
• D. Notify the healthcare provider immediately

Correct answer: D

Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment. Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected. Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation. Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.

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