Nursing Elites

1. What are the nursing priorities for a patient experiencing an asthma exacerbation?

• A. Administer a bronchodilator
• B. Encourage deep breathing
• C. Provide oxygen therapy
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.

2. What are the signs and symptoms of a potential infection?

• A. Fever, chills, and increased heart rate
• B. Increased white blood cell count and fever
• C. Shortness of breath and confusion
• D. Sweating and low blood pressure

Correct answer: A

Rationale: The correct answer is A: Fever, chills, and increased heart rate are classic signs of an infection. These symptoms indicate the body's response to an invading pathogen. Choice B, 'Increased white blood cell count and fever,' is not a primary symptom that a person would typically notice themselves, and white blood cell count needs to be tested. Choice C, 'Shortness of breath and confusion,' may indicate other conditions like heart or lung issues rather than a general infection. Choice D, 'Sweating and low blood pressure,' are not specific to infections and can be caused by various factors like heat or dehydration.

3. A client with an acute myocardial infarction is concerned about extreme fatigue. What is the best strategy to promote independence in self-care?

• A. Instruct the client to limit all activity until fully rested
• B. Encourage the client to gradually resume self-care tasks with rest periods
• C. Assign assistive personnel to complete self-care tasks
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with rest periods is the best strategy to promote independence in self-care for a client with acute myocardial infarction. This approach allows the client to regain independence while considering the need for rest to prevent overexertion. Instructing the client to limit all activity until fully rested (Choice A) may hinder independence by promoting inactivity. Assigning assistive personnel to complete self-care tasks (Choice C) does not promote the client's independence. Asking the client's family to assist with self-care (Choice D) may not foster the client's self-reliance and may not always be feasible.

4. A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?

• A. Use a bed exit alarm to notify staff of attempts to leave the bed
• B. Raise all four side rails for safety
• C. Encourage frequent ambulation with assistance
• D. Use restraints to prevent the client from getting out of bed

Correct answer: A

Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.

5. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

• A. Eat a light snack before bedtime.
• B. Stay in bed at least 1 hr if unable to fall asleep.
• C. Take a 1 hr nap during the day.
• D. Perform exercises prior to bedtime.

Correct answer: A

Rationale: The correct answer is to instruct the older adult client to eat a light snack before bedtime. This is beneficial as it helps prevent hunger, which can disrupt sleep. Choice B is incorrect as staying in bed for a prolonged time if unable to fall asleep can lead to frustration and worsen insomnia. Choice C is incorrect as taking a 1-hour nap during the day can interfere with the ability to fall asleep at night. Choice D is incorrect as performing exercises prior to bedtime can increase alertness and make it harder to fall asleep.

Similar Questions