Nursing Elites

1. The nurse observes an adolescent client preparing to administer a prescribed corticosteroid medication using a metered dose inhaler. What action should the nurse take?

• A. Remind the client to hold their breath after inhaling the medication
• B. Confirm that the client has correctly shaken the inhaler
• C. Affirm that the client has correctly positioned the inhaler
• D. Ask the client if they have a spacer to use for this medication

Correct answer: A

Rationale: Corrected Rationale: Reminding the client to hold their breath after inhaling the medication is crucial as it helps ensure the medication is absorbed into the lungs. Option B is incorrect because shaking the inhaler is not directly related to the client's inhalation technique. Option C is incorrect as correct positioning of the inhaler is important but not the immediate action needed in this situation. Option D is incorrect as asking about the spacer is not the most relevant action to take at this moment.

2. A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer intravenous fluids as prescribed.
• B. Administer insulin as prescribed.
• C. Monitor the client's urine output.
• D. Check the client's blood glucose level.

Correct answer: B

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. Insulin helps to reduce blood glucose levels and correct metabolic acidosis, which are critical in the treatment of DKA. While administering intravenous fluids is essential to manage dehydration, insulin takes precedence in treating the underlying cause of DKA. Monitoring urine output is important for assessing renal function but is not the primary intervention in managing DKA. Checking the client's blood glucose level is necessary, but administering insulin to reduce high blood glucose levels is the key priority in treating DKA.

3. An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

• A. Identify pills in the bag
• B. Review the client's medication schedule
• C. Assess the client's symptoms
• D. Educate the client about proper medication usage

Correct answer: A

Rationale: The correct answer is to identify pills in the bag first. This is essential to ensure the client is taking the correct medications and to prevent any potential medication errors. Reviewing the client's medication schedule (choice B) can come after identifying the pills to cross-reference the medications. Assessing the client's symptoms (choice C) is important but should follow identifying the medications. Educating the client about proper medication usage (choice D) is crucial but should be done after confirming the medications in the bag.

4. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. The infant was born two weeks after his due date and is described as a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

• A. Has your son had any immunizations yet?
• B. Is your son sleepy and difficult to feed?
• C. Are you breastfeeding or bottle-feeding your son?
• D. Were any relatives born with birth defects?

Correct answer: B

Rationale: The correct answer is B. Excessive sleepiness and difficulty feeding can be signs of hypothyroidism in infants. Asking about the infant's sleepiness and feeding pattern is crucial in assessing for hypothyroidism. Choice A is incorrect because immunizations are not directly related to hypothyroidism. Choice C is about feeding method and not specific to hypothyroidism. Choice D is unrelated as it asks about relatives with birth defects, which does not directly assess the infant's condition.

5. When assessing a client with left-sided heart failure, which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Monitor the client's urine output.
• C. Administer a loop diuretic as prescribed.
• D. Administer morphine as prescribed.

Correct answer: A

Rationale: Administering oxygen therapy is the initial intervention for a client with left-sided heart failure. This action is crucial in improving oxygen levels and reducing pulmonary congestion. Monitoring urine output is important for assessing renal function in heart failure, but it is not the priority over ensuring adequate oxygenation. Administering loop diuretics helps manage fluid overload but should come after addressing oxygen needs. Morphine may be indicated for pain or anxiety in some cases, but it is not the primary intervention for left-sided heart failure.

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