Nursing Elites

1. A client is experiencing shortness of breath and wheezing. What is the nurse's first action?

• A. Administer bronchodilator medication
• B. Check the client's oxygen saturation
• C. Encourage the client to use pursed-lip breathing
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention to open the airways and relieve wheezing and shortness of breath. Bronchodilators work quickly to dilate the airways, making it easier for the client to breathe. Checking oxygen saturation is important but can be done after initiating bronchodilator therapy. Encouraging pursed-lip breathing and elevating the head of the bed can help improve breathing patterns but should follow the administration of the bronchodilator.

2. A client with deep vein thrombosis (DVT) is receiving heparin and reports tarry stools. What should the nurse do?

• A. Prepare to administer warfarin.
• B. Assess characteristics of the client's pain.
• C. Monitor stools for blood and review PTT results.
• D. Continue the heparin and prepare to administer Vitamin K.

Correct answer: C

Rationale: When a client on heparin reports tarry stools, it can be indicative of gastrointestinal bleeding. The correct action for the nurse is to monitor the stools for blood and review the Partial Thromboplastin Time (PTT) results. This is essential to detect any potential bleeding complications associated with heparin therapy. Option A is incorrect because warfarin is not the immediate intervention for tarry stools in a client on heparin. Option B is irrelevant to the situation described. Option D is incorrect as Vitamin K is the antidote for warfarin, not heparin.

3. A client with chronic kidney disease is prescribed a low-sodium diet. What is the nurse's priority teaching?

• A. Choose fresh fruits and vegetables.
• B. Restrict fluid intake to 1500 mL per day.
• C. Limit sodium intake to 2 grams per day.
• D. Increase potassium intake to prevent hypokalemia.

Correct answer: C

Rationale: The correct answer is C: 'Limit sodium intake to 2 grams per day.' For a client with chronic kidney disease, limiting sodium intake is crucial because it helps prevent fluid retention and reduces the workload on the kidneys. Choice A, 'Choose fresh fruits and vegetables,' is generally a healthy dietary recommendation but not the priority when focusing on a low-sodium diet. Choice B, 'Restrict fluid intake to 1500 mL per day,' is important but secondary to limiting sodium intake. Choice D, 'Increase potassium intake to prevent hypokalemia,' is not the priority teaching for a client with chronic kidney disease on a low-sodium diet.

4. The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?

• A. Increased TSH
• B. Increased thyroxine (T4)
• C. Decreased TSH
• D. Decreased T3

Correct answer: A

Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.

5. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?

• A. Assess the client’s skin for lesions or sores.
• B. Monitor the client’s liver function tests.
• C. Assess for changes in mental status and behavior.
• D. Monitor the client’s urine output closely.

Correct answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.

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