Nursing Elites

1. What is the priority nursing intervention for a patient experiencing an acute asthma attack?

• A. Administer bronchodilators
• B. Administer corticosteroids
• C. Provide supplemental oxygen
• D. Start IV fluids

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as the priority nursing intervention for a patient with an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing acute asthma symptoms. Administering corticosteroids (Choice B) is also important in the treatment plan, but it is not the priority intervention during an acute attack. Providing supplemental oxygen (Choice C) may be necessary but is not the priority initial intervention. Starting IV fluids (Choice D) is not typically indicated as a priority intervention for an acute asthma attack.

2. A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. The client weighs 80 kg. How many mL/hr should the nurse set the IV infusion to deliver?

• A. 6 mL/hr
• B. 8 mL/hr
• C. 12 mL/hr
• D. 16 mL/hr

Correct answer: A

Rationale: To calculate the correct rate, use the formula: (4 mcg/kg/min * 80 kg) / 800 mcg in 250 mL = 6 mL/hr. This calculation is based on the dose ordered (4 mcg/kg/min) multiplied by the patient's weight in kg (80 kg), divided by the concentration of the drug available (800 mcg in 250 mL) to be infused over 1 hour. Therefore, the correct answer is 6 mL/hr. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided information.

3. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: B

Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).

4. A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?

• A. Constipation.
• B. Drowsiness.
• C. Orthostatic hypotension.
• D. Respiratory depression.

Correct answer: D

Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.

5. A client with a nasogastric tube receiving continuous enteral feedings is at risk for aspiration. Which of the following actions should the nurse take to prevent aspiration?

• A. Elevate the head of the bed to 15 degrees
• B. Check gastric residual volumes every 6 hours
• C. Monitor the pH of gastric aspirate
• D. Instill 10 mL of air into the tube before feeding

Correct answer: B

Rationale: Checking gastric residual volumes every 6 hours is essential in preventing aspiration in clients receiving continuous enteral feedings. This practice helps determine if the stomach is adequately emptying, reducing the risk of regurgitation and aspiration. Elevating the head of the bed to 30 degrees, not 15 degrees, is recommended to further prevent aspiration by reducing the risk of reflux. Monitoring the pH of gastric aspirate is important to assess tube placement but does not directly prevent aspiration. Instilling air into the tube before feeding is not a recommended practice and does not prevent aspiration.

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