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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. A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Beneficence
Correct answer: D
Rationale: In this scenario, offering pain medication to a postoperative client before ambulation is an example of beneficence. Beneficence is the ethical principle related to promoting the well-being of the client, which includes providing pain relief to improve the client's comfort and facilitate their recovery. Fidelity (choice A) is about honoring commitments and being faithful to agreements, not directly related to pain management. Autonomy (choice B) refers to respecting the client's right to make decisions about their care, not specifically about pain medication administration. Justice (choice C) involves fairness and equality in healthcare resource allocation, not directly applicable in this situation.
3. What is the most important nursing action when administering IV potassium?
- A. Monitor for decreased urine output
- B. Administer via IV push
- C. Administer slowly and dilute in IV fluids
- D. Ensure the client drinks 500 mL of water before administration
Correct answer: C
Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.
4. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect?
- A. Polyuria.
- B. Dehydration.
- C. Hyponatremia.
- D. Hyperglycemia.
Correct answer: C
Rationale: The correct answer is C: Hyponatremia. In SIADH, there is excessive release of antidiuretic hormone, causing water retention and dilutional hyponatremia. Polyuria (choice A) is increased urination, which is not a typical finding in SIADH. Dehydration (choice B) is the loss of body fluids, which is opposite to the fluid retention seen in SIADH. Hyperglycemia (choice D) is elevated blood sugar levels and is not directly related to SIADH.
5. 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.
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