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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 is the priority nursing intervention for a patient with chest pain?
- A. Administer nitroglycerin
- B. Assess pain level
- C. Monitor vital signs
- D. Provide oxygen therapy
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.
3. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?
- A. Use of tobacco might lead to alcohol and drug abuse.
- B. Smoking in adolescence increases the risk of developing lung cancer later in life.
- C. Use of tobacco decreases the level of athletic ability.
- D. Smoking in adolescence increases the risk of lifelong addiction.
Correct answer: C
Rationale: The most likely consequence to discourage adolescents from smoking is the immediate effect of decreased athletic ability. This consequence is more tangible and relevant to high school students compared to long-term health risks like lung cancer or addiction. While choices A, B, and D are all negative outcomes of smoking, choice C is more likely to have a direct impact on adolescents due to its immediate and visible effects on their physical performance.
4. A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which of the following information should the nurse include?
- A. Frequent hand washing prevents infection
- B. Prolonged use of corticosteroids increases infection risk
- C. Limit patient interaction to reduce infection spread
- D. Restrict client movement to prevent contamination
Correct answer: B
Rationale: The correct answer is B because prolonged use of corticosteroids is a known risk factor for infections. Choice A is incorrect because frequent hand washing actually helps prevent infections. Choice C is incorrect as patient interaction is essential in healthcare but should be done following proper infection control measures. Choice D is also incorrect as restricting client movement is not a standard practice to prevent contamination.
5. A healthcare professional is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the healthcare professional recommend?
- A. Suction the airway every hour
- B. Keep the head of the bed at 30 degrees
- C. Change the ventilator tubing every day
- D. Administer a bronchodilator every 2 hours
Correct answer: B
Rationale: The correct answer is to keep the head of the bed at 30 degrees. This position helps reduce the risk of aspiration and improves ventilation. Suctioning the airway every hour may lead to mucosal damage and increase the risk of infection. Changing the ventilator tubing every day is not necessary unless there are specific indications to do so, as it can increase the risk of contamination and infection. Administering a bronchodilator every 2 hours is not a standard practice and should be done based on the client's individualized treatment plan.
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