Nursing Elites

1. The parents of a 6-year-old recently diagnosed with asthma should be taught that symptoms of an acute episode of asthma are due to which physiological response?

• A. Inflammation of the mucous membrane and bronchospasm
• B. Increased mucus production and airway obstruction
• C. Hyperinflation of the lungs and alveolar collapse
• D. Bronchoconstriction and airway inflammation

Correct answer: D

Rationale: The correct answer is D: Bronchoconstriction and airway inflammation. During an acute asthma episode, bronchoconstriction and airway inflammation occur, leading to difficulty breathing. Choices A, B, and C are incorrect. Inflammation of the mucous membrane and bronchospasm (Choice A) are part of the pathophysiology of asthma but do not fully explain the symptoms during an acute episode. Increased mucus production and airway obstruction (Choice B) are also seen in asthma but are not the primary cause of acute symptoms. Hyperinflation of the lungs and alveolar collapse (Choice C) are not typical features of an acute asthma episode.

2. A client with hypertension is prescribed a calcium channel blocker. Which client statement indicates that further teaching is needed?

• A. ‘I will take my medication at the same time every day.’
• B. ‘I should avoid drinking grapefruit juice while on this medication.’
• C. ‘I should increase my intake of calcium-rich foods.’
• D. ‘I should reduce my fluid intake to control my blood pressure.’

Correct answer: D

Rationale: The correct answer is D. The statement ‘I should reduce my fluid intake to control my blood pressure’ indicates a misunderstanding. It is important to note that fluid restriction is not typically necessary when taking calcium channel blockers. Choices A, B, and C demonstrate good understanding of medication adherence, dietary precautions, and nutrition recommendations when taking a calcium channel blocker, making them incorrect choices for further teaching.

3. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

• A. Observe for unilateral swelling
• B. Administer pain medication
• C. Elevate the leg and apply a warm compress
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.

4. The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Complaint of headaches and stiff neck.
• B. Complaint of dizziness and nausea.
• C. Increased pain at the puncture site.
• D. Mild redness around the puncture site.

Correct answer: A

Rationale: The correct answer is A: Complaint of headaches and stiff neck. Headaches and stiff neck following a myelogram may indicate a cerebrospinal fluid (CSF) leak or other complications that require prompt medical attention. Reporting this finding immediately is crucial to prevent further complications. Choices B, C, and D are incorrect because while they may warrant monitoring and intervention, they are not as indicative of a potentially serious complication as the symptoms described in choice A.

5. Which nursing intervention has the highest priority for a multigravida who delivered an hour ago?

• A. Maintain cold packs to the perineum for 24 hours.
• B. Assess the client's pain level frequently.
• C. Observe for appropriate interaction with the infant.
• D. Assess fundal tone and lochia flow.

Correct answer: D

Rationale: Assessing fundal tone and lochia flow is crucial in the immediate postpartum period to detect postpartum hemorrhage, a life-threatening complication. Monitoring these parameters allows for early identification of excessive bleeding, enabling prompt intervention. While maintaining cold packs to the perineum, assessing pain levels, and observing for appropriate interaction with the infant are important aspects of postpartum care, assessing fundal tone and lochia flow takes precedence due to its direct relevance to identifying and managing a potential emergency situation.

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