Nursing Elites

1. A client with asthma is experiencing wheezing. What is the nurse’s priority intervention?

• A. Administer a bronchodilator immediately.
• B. Increase the client's oxygen flow rate.
• C. Perform a chest x-ray to assess lung function.
• D. Place the client in a high Fowler’s position.

Correct answer: A

Rationale: The correct answer is A: Administer a bronchodilator immediately. Wheezing in a client with asthma indicates bronchoconstriction, which can compromise airflow. Administering a bronchodilator is the priority intervention as it helps to open the airways, relieve bronchoconstriction, and improve breathing. Increasing the oxygen flow rate (choice B) may be necessary but is not the priority when the airways are constricted. Performing a chest x-ray (choice C) is not the immediate action needed in this situation. Placing the client in a high Fowler's position (choice D) may provide some relief, but administering a bronchodilator to address the bronchoconstriction is the priority intervention.

2. The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?

• A. Calcium level
• B. Sodium level
• C. Magnesium level
• D. Potassium level

Correct answer: D

Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.

3. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?

• A. Side-lying on the left with the head elevated 10 degrees
• B. Side-lying on the left with the head elevated 35 degrees
• C. Side-lying on the right with the head elevated 10 degrees
• D. Side-lying on the right with the head elevated 35 degrees

Correct answer: A

Rationale: The correct answer is side-lying on the left with the head elevated 10 degrees. This position maximizes ventilation and promotes better perfusion to the unaffected lung. Placing the client in this position helps to optimize oxygenation and reduce pressure on the affected lung. Choices B, C, and D are incorrect because lying on the left side with the head elevated is essential to facilitate better lung expansion and gas exchange in the unaffected lung, while lying on the right side could further compromise the affected lung by increasing pressure on it.

4. A client with heart failure is prescribed furosemide. The nurse notes that the client's potassium level is 3.1 mEq/L. What is the nurse's priority action?

• A. Administer a potassium supplement
• B. Encourage the client to eat potassium-rich foods
• C. Hold the next dose of furosemide
• D. Increase the client's fluid intake

Correct answer: A

Rationale: A potassium level of 3.1 mEq/L is considered low, indicating hypokalemia. Administering a potassium supplement is the nurse's priority action to prevent complications such as cardiac arrhythmias associated with low potassium levels. Encouraging the client to eat potassium-rich foods is beneficial in the long term but may not rapidly correct the low potassium level. Holding the next dose of furosemide may worsen the client's heart failure symptoms. Increasing the client's fluid intake is not the priority action in this situation; addressing the low potassium level takes precedence to prevent potential serious complications.

5. A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?

• A. Decreased pain and increased redness around the ulcer.
• B. Increased serous drainage from the ulcer site.
• C. Cool extremities and weak peripheral pulses.
• D. Pitting edema around the ulcer site.

Correct answer: C

Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.

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