Nursing Elites

1. During an acute exacerbation of asthma, what is the nurse's first action for a client experiencing this condition?

• A. Administer a bronchodilator as prescribed.
• B. Check the client's oxygen saturation.
• C. Reassure the client and encourage deep breathing.
• D. Provide emotional support to reduce anxiety.

Correct answer: A

Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (Choice B) is important but not the first action. Reassuring the client and encouraging deep breathing (Choice C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (Choice D) is important but is not the initial priority in managing an acute exacerbation of asthma.

2. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide?

• A. Avoid foods high in vitamin K, such as spinach.
• B. Report any signs of bleeding, such as bruising or nosebleeds.
• C. Take the medication on an empty stomach.
• D. Monitor for changes in blood pressure.

Correct answer: B

Rationale: The correct teaching for a client prescribed warfarin is to report any signs of bleeding, such as unusual bruising, nosebleeds, or blood in the urine or stool. Warfarin is an anticoagulant that increases the risk of bleeding, so it is crucial for the client to promptly report any bleeding-related symptoms for evaluation by a healthcare provider. Choices A, C, and D are incorrect. Avoiding foods high in vitamin K, such as spinach, is more relevant for clients taking warfarin to maintain consistent vitamin K intake. Warfarin should be taken with food to avoid gastrointestinal upset, so taking it on an empty stomach is not recommended. Monitoring for changes in blood pressure is not directly related to warfarin therapy; instead, the focus should be on monitoring for signs of bleeding.

3. The nurse is preparing a female client for discharge after being treated for a urinary tract infection (UTI). Which statement by the client indicates a need for further teaching?

• A. I will use douches regularly to prevent future infections.
• B. I should drink at least 8 glasses of water a day.
• C. I should avoid tight-fitting clothing.
• D. I will wipe from front to back after using the toilet.

Correct answer: A

Rationale: The correct answer is A. Using douches is not recommended as it can disrupt the natural flora and increase the risk of infections. Choices B, C, and D are all correct statements that can help prevent UTIs. Drinking an adequate amount of water helps flush out bacteria, avoiding tight-fitting clothing promotes ventilation and reduces moisture, and wiping from front to back prevents the spread of bacteria from the anal region to the urethra.

4. A male client reports that he took tadalafil 10 mg two hours ago and now feels flushed. What action should the nurse take?

• A. Instruct the client to increase oral fluid intake.
• B. Reassure the client that flushing is a common side effect.
• C. Advise the client to take nitroglycerin as a precaution.
• D. Ask the client to come to the emergency room.

Correct answer: B

Rationale: The correct answer is B: Reassure the client that flushing is a common side effect. Tadalafil, a medication used for erectile dysfunction, can cause flushing as a common side effect. In this situation, the nurse should provide reassurance to the client that the flushing is expected and not necessarily a cause for concern. Increasing oral fluid intake (choice A) may be beneficial for other conditions but is not directly related to tadalafil-induced flushing. Advising the client to take nitroglycerin (choice C) is incorrect, as nitroglycerin is not indicated for flushing. Asking the client to come to the emergency room (choice D) is unnecessary at this point since flushing is a known side effect and does not typically require urgent medical attention.

5. The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?

• A. Deltoid muscle
• B. Ventrogluteal muscle
• C. Vastus lateralis muscle
• D. Dorsogluteal muscle

Correct answer: B

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.

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