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1. What are the nursing priorities for a patient experiencing an asthma exacerbation?
- A. Administer a bronchodilator
- B. Encourage deep breathing
- C. Provide oxygen therapy
- D. Monitor oxygen saturation
Correct answer: A
Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.
2. A nurse is reviewing the medical record of a client who is taking enalapril for hypertension. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 150/80 mm Hg
- B. Swelling in the legs
- C. Persistent cough
- D. Heart rate of 72 beats per minute
Correct answer: C
Rationale: The correct answer is C: Persistent cough. Enalapril is known to cause a persistent dry cough as a side effect. This adverse reaction is due to the accumulation of bradykinin in the lungs, leading to irritation and cough. The nurse should report this symptom to the provider for further evaluation and possible medication adjustment. Choices A, B, and D are not directly associated with enalapril use. While a blood pressure of 150/80 mm Hg is elevated and should be monitored, it is not a direct side effect of enalapril. Swelling in the legs and a heart rate of 72 beats per minute are also not typically related to enalapril use and should be assessed but are not the priority findings to report in this scenario.
3. What are early indicators of dehydration?
- A. Dry mouth
- B. Increased thirst
- C. Decreased urine output
- D. Dizziness
Correct answer: A
Rationale: The correct answer is A, dry mouth, and B, increased thirst are early indicators of dehydration. Dry mouth occurs when the body is dehydrated, and increased thirst is the body's way of trying to increase fluid intake to combat dehydration. Choices C and D, decreased urine output and dizziness, can be signs of severe dehydration but are not typically considered early indicators.
4. When caring for a client diagnosed with delirium, what condition should the nurse prioritize investigating?
- A. Investigate medication history
- B. Investigate sensory deficits
- C. Investigate cognitive functioning
- D. Investigate for signs of infection
Correct answer: D
Rationale: The correct answer is to investigate for signs of infection when caring for a client diagnosed with delirium. Infections can frequently cause or worsen delirium. While investigating medication history, sensory deficits, and cognitive functioning may be important in the overall care of the client, when prioritizing, the nurse should first rule out or address potential infections due to their significant impact on delirium.
5. A client with hypertension is receiving lifestyle education from a nurse. What should be emphasized?
- A. Encourage a low-sodium diet
- B. Advise the client to avoid caffeinated drinks
- C. Recommend increasing high-protein foods
- D. Advise the client to reduce fat intake
Correct answer: B
Rationale: The correct answer is to advise the client to avoid caffeinated drinks. Caffeine can temporarily increase blood pressure, so avoiding caffeinated drinks can help manage hypertension. Encouraging a low-sodium diet (Choice A) is essential for hypertension management as excess sodium can raise blood pressure. Increasing high-protein foods (Choice C) is not a primary focus in managing hypertension. While reducing fat intake (Choice D) can be beneficial for overall health, it is not the priority in lifestyle modifications for hypertension.
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