Nursing Elites

1. A 14-year-old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent?

• A. Nervousness should disappear when hypoxia is relieved after several bronchodilator treatments
• B. Tremors result from the rapid dilation of the bronchioles and an increased heart rate
• C. A fast heart rate and jitteriness are side effects of the bronchodilator treatment containing albuterol
• D. Excessive coughing, which causes tachypnea and anxiety, result from the use of bronchodilators

Correct answer: C

Rationale: The correct answer is C because a fast heart rate and jitteriness are common side effects of bronchodilators like albuterol. Choice A is incorrect as nervousness is more likely a side effect of the medication than solely related to hypoxia. Choice B is incorrect as it provides a partial explanation focusing only on tremors and heart rate, not mentioning jitteriness. Choice D is incorrect because excessive coughing and tachypnea are not typically associated with bronchodilator use; instead, they may indicate inadequate relief or other issues.

2. The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?

• A. Calcium
• B. Sodium
• C. Chloride
• D. Potassium

Correct answer: A

Rationale: Corrected Rationale: Monitoring calcium levels is crucial post-thyroid surgery to detect hypocalcemia, a common complication due to injury or removal of the parathyroid glands. Monitoring sodium, chloride, or potassium levels is not as vital in the immediate post-thyroid surgery period.

3. What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?

• A. Avoid douching
• B. Treat sexual partner(s) concurrently
• C. Avoid using moist washcloths when bathing
• D. Postpone becoming pregnant until the infection is treated

Correct answer: B

Rationale: The most important instruction for a female client diagnosed with trichomoniasis is to treat sexual partner(s) concurrently. This is crucial to prevent reinfection and the spread of the infection. Choice A, avoiding douching, is generally recommended for vaginal health but is not the most critical instruction in this case. Choice C, avoiding moist washcloths when bathing, is not directly related to the transmission or treatment of trichomoniasis. Choice D, postponing pregnancy until the infection is treated, is important but treating sexual partners concurrently takes precedence to prevent reinfection.

4. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been 'trying to start a new business' and is 'too busy to eat.' He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?

• A. Self-care deficit
• B. Disturbed sleep pattern
• C. Disturbed thought processes
• D. Imbalanced nutrition

Correct answer: D

Rationale: Imbalanced nutrition is the most critical nursing diagnosis to address in this scenario. The patient's significant weight loss and neglect of basic needs, such as eating and personal hygiene, indicate a severe imbalance in nutrition. Addressing this issue is crucial to prevent further health deterioration. Self-care deficit, disturbed sleep pattern, and disturbed thought processes are important but secondary concerns compared to the immediate risk posed by imbalanced nutrition. While self-care deficit and disturbed sleep pattern are valid concerns, the patient's weight loss and neglect of basic needs take precedence. Disturbed thought processes are also significant but addressing the imbalanced nutrition is more urgent in this context.

5. The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?

• A. Daily intake and output
• B. Skin turgor
• C. Daily weight
• D. Vital signs every 4 hours

Correct answer: C

Rationale: Daily weight is the most important data for the nurse to obtain in determining the client's fluid status in this scenario. During febrile episodes, assessing daily weight is crucial as it can indicate fluid retention or loss. While monitoring intake and output is important for assessing fluid balance, daily weight provides a more comprehensive picture of fluid status over time. Skin turgor is more indicative of hydration status than overall fluid status, and vital signs, although essential, do not directly assess fluid status as effectively as daily weight.

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