Nursing Elites

1. The client is wheezing and struggling to breathe. Which of the inhaled medications is indicated at this time?

• A. Fluticasone (Flovent)
• B. Salmeterol (Serevent)
• C. Theophylline (Theodur)
• D. Albuterol (Atrovent)

Correct answer: D

Rationale: The correct answer is Albuterol (Atrovent) because it is a rapid-acting bronchodilator, essential for a client experiencing wheezing and difficulty breathing. Albuterol acts quickly, dilating the airways and providing immediate relief in cases of respiratory distress. Fluticasone (Flovent) and Salmeterol (Serevent) are maintenance medications for long-term asthma control, not suitable for acute situations described. Theophylline (Theodur) is a bronchodilator but with a slower onset compared to Albuterol, making it less appropriate for a client in immediate distress.

2. Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?

• A. Wearing clean gloves while performing a heel stick on an infant
• B. Wearing the same gloves for assessments of clients in the same room
• C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
• D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus

Correct answer: A

Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.

3. A patient's nurse taking a history notes complaints of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia and hypertension. Which of the following may be occurring?

• A. The patient may be developing CHF
• B. The patient may be having a MI
• C. The patient may be developing COPD
• D. The patient may be having an onset of PVD

Correct answer: B

Rationale: In this scenario, the patient's symptoms of shortness of breath (SOB) and weakness in the lower extremities, along with a history of hyperlipidemia and hypertension, are suggestive of a myocardial infarction (MI). It is important to note that MI can present with a variety of symptoms, including those affecting the respiratory system and muscle weakness. Choices A, C, and D are incorrect because the patient's symptoms are more indicative of a myocardial infarction rather than congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or peripheral vascular disease (PVD).

4. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2 if necessary.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary.

Correct answer: D

Rationale: The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (Choice A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (Choice B) is not required for early decelerations. Notifying the physician (Choice C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.

5. A patient has been diagnosed with Guillain-Barre Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre Syndrome with the patient?

• A. Guillain-Barre Syndrome improves in almost all cases within 5 years.
• B. Guillain-Barre Syndrome causes limited sensation in the abdominal region.
• C. Guillain-Barre Syndrome causes muscle weakness in the legs.
• D. Guillain-Barre Syndrome affects breathing in severe cases.

Correct answer: C

Rationale: The correct statement is that Guillain-Barre Syndrome causes muscle weakness in the legs. This muscle weakness typically starts in the legs and can progress to the upper body. Choice A is incorrect as while most cases do improve, the recovery time can vary. Choice B is incorrect as Guillain-Barre Syndrome primarily affects muscle weakness rather than sensation. Choice D is incorrect as severe cases of Guillain-Barre Syndrome can lead to respiratory muscle weakness, impacting breathing.

Similar Questions