Nursing Elites

1. A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?

• A. Administer an epinephrine injection
• B. Call for immediate medical help
• C. Monitor airway, breathing, and circulation
• D. All of the above

Correct answer: A

Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.

2. The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

• A. Increase sodium intake.
• B. Engage in regular physical activity.
• C. Avoid foods high in fat.
• D. Limit fluid intake to 1 liter per day.

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.

3. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?

• A. Increase the oxygen flow rate according to the prescription
• B. Encourage the client to perform pursed-lip breathing
• C. Prepare for emergency intubation
• D. Assess the client's oxygen saturation and breath sounds

Correct answer: D

Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.

4. During a severe asthma exacerbation in a client, what is the nurse's priority?

• A. Administer a rescue inhaler immediately
• B. Prepare for intubation
• C. Encourage deep breathing exercises
• D. Monitor oxygen saturation levels

Correct answer: A

Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.

5. What intervention has the highest priority for a client with a fourth-degree midline laceration following the vaginal delivery of an 8-pound 10-ounce infant?

• A. Administer a prescribed stool softener
• B. Administer prescribed PRN sleep medications
• C. Encourage breastfeeding to promote uterine involution
• D. Encourage the use of prescribed analgesic perineal sprays

Correct answer: A

Rationale: Administering a prescribed stool softener is the highest priority intervention for a client with a fourth-degree midline laceration to prevent straining during bowel movements, which could potentially harm the healing laceration. Stool softeners help in maintaining soft stools, reducing the risk of injury to the suture line. Administering PRN sleep medications, encouraging breastfeeding, or promoting the use of analgesic perineal sprays are important aspects of care but are not the priority in this situation. Stool softeners play a crucial role in preventing complications and promoting healing in such cases, making it the most urgent intervention.

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