Nursing Elites

1. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?

• A. Auscultation of breath sounds
• B. Measurement of peak expiratory flow
• C. Observation of the client's use of accessory muscles
• D. Assessment of the client's skin color

Correct answer: A

Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.

2. After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?

• A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
• B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
• C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
• D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Correct answer: D

Rationale: The correct answer is D. A meal of turkey, sweet potato, green beans, milk, and an orange is low in sodium and suitable for a post-MI diet. Choice A includes a baked potato and canned beets, which are higher in sodium. Choice B includes canned salmon, which can be high in sodium. Choice C includes a bologna sandwich, which is also high in sodium compared to the other options.

3. A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?

• A. Risk for injury related to exophthalmos
• B. Impaired social interaction related to emotional lability
• C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
• D. Activity intolerance related to fatigue

Correct answer: D

Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.

4. A client who has received treatment for kidney stones should be reminded to increase intake of which of the following?

• A. Tea
• B. Sodium
• C. Water
• D. Protein

Correct answer: C

Rationale: The correct answer is C: Water. Increasing water intake helps prevent the formation of new kidney stones by diluting the urine. Tea (Choice A) contains oxalates, which can contribute to kidney stone formation. Sodium (Choice B) should be limited to prevent the risk of certain types of kidney stones. Protein (Choice D) intake should be moderate as excessive protein consumption may increase the risk of kidney stones. Therefore, advising the client to increase water intake is the most appropriate recommendation to prevent the recurrence of kidney stones.

5. After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to melt ice chips in the mouth
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.

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