Nursing Elites

1. A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)

• A. Administer prescribed salmeterol (Serevent) inhaler.
• B. Assess the client for a tracheal deviation.
• C. Administer oxygen to maintain saturations above 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation suggests the client is using accessory muscles due to difficulty in moving air into the respiratory passages caused by airway narrowing. The presence of bilateral wheezing and decreased pulse oxygen saturation further support airway narrowing. In this situation, immediate intervention is necessary to improve oxygenation. Administering oxygen to maintain saturations above 94% is crucial to support oxygenation. While administering a rescue inhaler may be warranted, the priority in this scenario is ensuring adequate oxygenation to address the respiratory distress.

2. A client is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?

• A. Smoking while taking this medication will increase your risk of a stroke.
• B. Make a list of reasons why smoking is a bad habit.
• C. Stopping this medication suddenly increases your risk for a heart attack.
• D. Rise slowly when getting out of bed in the morning.

Correct answer: A

Rationale: When a client is prescribed nicotine replacement therapy, it is crucial to emphasize that smoking while using this therapy can increase the risk of a stroke. Smoking while on nicotine replacement therapy can lead to excessive nicotine levels in the body, elevating cardiovascular risks. Therefore, the nurse should educate the client on the importance of avoiding smoking while utilizing this medication. Choices B, C, and D are not relevant to the specific teaching required for a client on nicotine replacement therapy.

3. While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?

• A. Airway obstruction
• B. Infection
• C. Fluid imbalance
• D. Paralytic ileus

Correct answer: A

Rationale: When a client sustains burns to the head, neck, or chest, the risk of airway obstruction is a critical concern due to potential swelling, inflammation, or inhalation injury. Any compromise to the airway can lead to severe respiratory distress or failure. Early recognition and intervention to maintain a clear airway are essential to prevent life-threatening complications in burn patients.

4. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?

• A. Weight gain of 1 kg since the last dialysis session
• B. Blood pressure of 150/90 mm Hg
• C. Potassium level of 6.5 mEq/L
• D. Hemoglobin level of 10 g/dL

Correct answer: C

Rationale: A potassium level of 6.5 mEq/L is critically high and can lead to life-threatening cardiac dysrhythmias, requiring immediate intervention. Hyperkalemia is a common complication in clients with ESRD due to the kidneys' inability to excrete potassium effectively. High potassium levels can result in serious cardiac consequences such as arrhythmias, cardiac arrest, and death. Prompt action is necessary to prevent these severe complications.

5. A client's arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The client is experiencing which of the following acid-base imbalances?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: C

Rationale: In respiratory acidosis, there is an excess of carbon dioxide (PaCO2 > 45 mm Hg) leading to a decrease in pH (<7.35). The given values of a pH of 7.3 and PaCO2 of 50 mm Hg indicate respiratory acidosis. Metabolic acidosis involves a primary decrease in bicarbonate levels with a compensatory decrease in PaCO2 to maintain balance. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. Respiratory alkalosis is marked by low PaCO2 and increased pH levels.

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