👉 Albuterol is a short-acting beta₂-adrenergic agonist (SABA) and is the first-line medication for an acute asthma attack.

👉 It works by causing rapid bronchodilation, which relaxes bronchial smooth muscle and opens narrowed airways.

👉 During an acute asthma exacerbation, the priority is to restore airway patency and improve oxygen exchange.

👉 Albuterol provides quick relief of symptoms such as wheezing, shortness of breath, chest tightness, and difficulty breathing.

👉 It has a rapid onset of action, typically beginning within minutes, making it appropriate for emergency relief.

👉 The nurse should assess the patient's respiratory status, oxygen saturation, breath sounds, and response to treatment after administration.

👉 Other asthma medications may help with long-term control but do not provide immediate relief during an acute attack.

👉 Therefore, albuterol should be administered first to quickly relieve bronchoconstriction.

❌ Fluticasone

👉 Fluticasone is an inhaled corticosteroid used for long-term asthma control by reducing airway inflammation.

👉 It does not provide rapid bronchodilation and is not effective as a rescue medication during an acute asthma attack.

❌ Montelukast

👉 Montelukast is a leukotriene receptor antagonist used for asthma maintenance and prevention.

👉 It does not act quickly enough to relieve acute bronchospasm.

❌Salmeterol

👉 Salmeterol is a long-acting beta₂-agonist (LABA) used for long-term asthma control.

👉 It has a slower onset and should not be used alone or as a rescue medication during an acute asthma attack.

👉 The goal of tracheostomy suctioning is to remove accumulated secretions from the airway and maintain airway patency.

👉 Clear breath sounds indicate that secretions have been successfully removed and air is moving freely through the respiratory tract.

👉 Before suctioning, a client with a tracheostomy may have coarse crackles, rhonchi, noisy breathing, or decreased air movement due to retained secretions.

👉 After effective suctioning, the nurse should expect improved airflow, clearer lung sounds, and easier breathing.

👉 Effective suctioning also helps improve oxygenation by reducing airway obstruction caused by mucus buildup.

👉 The nurse should continue to monitor respiratory status, oxygen saturation, respiratory effort, and the amount and characteristics of secretions.

👉 Clear breath sounds are a positive indicator that the airway is cleaner and ventilation has improved.

👉 Therefore, clear breath sounds indicate effective tracheostomy suctioning.

❌ B. Client becomes cyanotic

👉 Cyanosis indicates decreased oxygenation and is a sign of respiratory compromise.

👉 It suggests that suctioning may have caused hypoxia or that airway obstruction remains, not that the procedure was effective.

❌ C. Client reports throat pain

👉 Mild discomfort can occur during suctioning, but throat pain does not indicate that secretions were successfully removed.

👉 Pain is an adverse effect or discomfort related to the procedure, not an assessment of effectiveness.

❌ D. Pulse oximetry decreases during suctioning

👉 A temporary decrease in oxygen saturation can occur during suctioning because the airway is briefly interrupted.

👉 However, a drop in oxygen saturation is not an indicator of effective suctioning and may signal hypoxia or the need for better technique.

👉 Fatigue is one of the most common and disabling symptoms of multiple sclerosis (MS) and can worsen with excessive activity or stress.

👉 The priority nursing intervention is to help the client conserve energy while maintaining independence and function.

👉 Providing scheduled rest periods throughout the day prevents excessive exhaustion and allows the client to complete necessary activities more effectively.

👉 Energy conservation techniques help reduce fatigue by balancing periods of activity with planned periods of rest.

👉 The nurse should encourage the client to perform important activities during times when energy levels are highest.

👉 Rest periods should be planned before the client becomes extremely fatigued because recovery may take longer once exhaustion occurs.

👉 The nurse should also teach strategies such as prioritizing tasks, using assistive devices when needed, and avoiding overheating.

👉 Therefore, providing rest periods during the day is the priority intervention for managing MS-related fatigue.

❌ Avoid all physical activity

👉 Complete avoidance of activity is not recommended because inactivity can lead to muscle weakness, decreased endurance, and reduced mobility.

👉 Clients with MS benefit from moderate, planned exercise with adequate rest periods.

❌ Promote exercise in the evening

👉 Exercise is beneficial, but evening exercise may worsen fatigue because many clients experience increased tiredness later in the day.

👉 Activities should be scheduled when the client has the most energy, often earlier in the day.

❌ Encourage long naps in the afternoon

👉 Excessive daytime sleeping can interfere with nighttime sleep patterns and may increase overall fatigue.

👉 Short, planned rest periods are preferred over prolonged naps.

👉 Fatigue is a major symptom of multiple sclerosis (MS) caused by neurological changes, increased energy requirements for movement, and impaired nerve conduction.

👉 The priority nursing intervention is energy conservation, which involves balancing activity with planned rest periods.

👉 Providing rest periods throughout the day prevents excessive fatigue and allows the client to maintain independence with daily activities.

👉 Scheduled rest helps the client complete important tasks during periods when energy levels are higher.

👉 The nurse should encourage the client to plan activities, prioritize essential tasks, and rest before becoming exhausted.

👉 Rest periods are more effective when they are planned rather than waiting until severe fatigue occurs.

👉 Maintaining some level of activity is important because inactivity can lead to muscle weakness and decreased mobility.

👉 Therefore, providing rest periods during the day is the priority intervention for MS-related fatigue.

❌ Avoid all physical activity

👉 Avoiding all activity is not recommended because it can cause muscle deconditioning, weakness, and reduced endurance.

👉 Clients with MS benefit from appropriate exercise combined with rest and energy conservation.

❌Promote exercise in the evening

👉 Exercise can help improve strength and endurance, but evening exercise may worsen fatigue because energy levels are often lower later in the day.

👉 Exercise is usually better scheduled during times when the client has the most energy.

❌Encourage long naps in the afternoon

👉 Long naps may interfere with nighttime sleep and disrupt the normal sleep cycle.

👉 Short, planned rest periods are preferred to help manage fatigue without causing additional sleep problems.

👉 Diabetic ketoacidosis (DKA) occurs when there is not enough insulin available for glucose to enter cells, causing the body to break down fat for energy.

👉 Fat metabolism produces ketone bodies, which accumulate in the blood and urine.

👉 A positive urine ketone result is a key finding that supports the diagnosis of DKA.

👉 Ketone accumulation causes the blood to become acidic, leading to metabolic acidosis.

👉 Other common findings in DKA include:

Elevated blood glucose levels

Decreased blood pH

Decreased bicarbonate levels

Increased anion gap

Dehydration

Electrolyte imbalances

👉 Detecting ketones helps confirm that the body is using fat as an alternative energy source due to insulin deficiency.

👉 Therefore, urine positive for ketones is the laboratory result that supports a diagnosis of DKA.

❌ Blood pH 7.46 (Normal: 7.35–7.45)

👉 A pH of 7.46 indicates alkalosis, not acidosis.

👉 DKA causes metabolic acidosis, which would result in a decreased pH (typically below 7.35).

❌ Serum glucose 150 mg/dL (Normal: 90–140 mg/dL)

👉 Although this glucose level is slightly elevated, it is not consistent with typical DKA, where glucose is usually significantly elevated (often >250 mg/dL).

👉 Mild elevation alone does not indicate ketoacidosis.

❌ Serum potassium 4.1 mEq/L (Normal: 3.5–5.0 mEq/L)

👉 A potassium level of 4.1 mEq/L is within the normal range.

👉 Potassium abnormalities may occur in DKA, but a normal potassium level does not confirm the diagnosis.

👉 Primary hyperparathyroidism occurs when the parathyroid glands produce excessive amounts of parathyroid hormone (PTH).

👉 Increased PTH causes the body to remove calcium from the bones and increase calcium absorption and retention.

👉 The major laboratory finding associated with primary hyperparathyroidism is hypercalcemia (elevated serum calcium levels).

👉 PTH increases:

Bone resorption → calcium is released from bones into the bloodstream.

Kidney calcium reabsorption → less calcium is lost in urine.

Vitamin D activation → increased calcium absorption from the intestines.

👉 Elevated calcium levels can lead to symptoms such as:

Kidney stones

Bone pain and fractures

Muscle weakness

Constipation

Fatigue

Confusion

👉 The classic concept is: “High PTH = High calcium.”

👉 Therefore, a client with an increased calcium level demonstrates a manifestation of primary hyperparathyroidism.

❌ The client who has a decreased parathyroid hormone level

👉 Primary hyperparathyroidism is caused by excessive secretion of PTH, not decreased PTH.

👉 A low PTH level is associated with hypoparathyroidism, which commonly causes decreased calcium levels.

❌ The client who has a decreased potassium level

👉 Potassium levels are not the primary electrolyte affected by parathyroid hormone.

👉 Primary hyperparathyroidism mainly affects calcium and phosphate balance, not potassium regulation.

❌ The client who has an increased sodium level

👉 Sodium levels are regulated mainly by fluid balance, kidney function, and hormones such as aldosterone and ADH.

👉 Increased sodium is not a characteristic finding of primary hyperparathyroidism.

👉 Bell’s palsy is an acute paralysis of the facial nerve (cranial nerve VII) that causes sudden unilateral facial weakness or paralysis.

👉 Because the facial nerve controls the muscles responsible for eyelid closure, affected clients may be unable to fully close the eye.

👉 Inability to close the eye places the client at risk for:

Corneal drying

Eye irritation

Corneal abrasions

Eye infection or injury

👉 An eye patch helps protect the affected eye by preventing exposure to environmental irritants and reducing the risk of corneal damage.

👉 Artificial tears provide lubrication to maintain moisture and protect the cornea when normal blinking and tear distribution are impaired.

👉 Eye protection is the priority nursing concern because preventing permanent eye injury is essential while nerve function returns.

👉 The nurse should also encourage the client to report eye pain, redness, or vision changes, which may indicate corneal complications.

👉 Therefore, eye patch use and artificial tears are the most appropriate interventions for Bell’s palsy.

❌Place the client on strict bed rest to prevent fatigue

👉 Strict bed rest is not indicated for Bell’s palsy.

👉 Clients should maintain normal activity as tolerated because prolonged inactivity can lead to unnecessary complications such as weakness and deconditioning.

❌Restrict oral intake to prevent aspiration

👉 Oral intake is not routinely restricted in Bell’s palsy.

👉 Although facial weakness may affect chewing or swallowing in some clients, the nurse should assess swallowing ability rather than automatically restricting fluids and food.

❌ Encourage facial massage to the affected side every hour

👉 Facial massage may be used during recovery in some cases, but it is not the priority intervention.

👉 The immediate concern is protecting the exposed eye from injury due to inability to close the eyelid.

👉 Clients with dementia have an increased risk of falls and injuries due to confusion, impaired judgment, decreased coordination, and changes in mobility.

👉 Removing tripping hazards is an important safety intervention that reduces the risk of falls in the home environment.

👉 The caregiver should remove or secure hazards such as:

Loose rugs

Electrical cords

Clutter in walkways

Poorly placed furniture

👉 A safe environment helps the client maintain independence while reducing preventable injuries.

👉 Additional safety measures include adequate lighting, installing handrails, using nonslip footwear, and keeping frequently used items within reach.

👉 Dementia care focuses on promoting safety while allowing the client to participate in daily activities as much as possible.

👉 Therefore, removing tripping hazards demonstrates that the caregiver understands appropriate home safety measures.

❌ "I will lock all of the bedroom doors."

👉 Locking bedroom doors may create a safety hazard by preventing the client from exiting during emergencies.

👉 Clients with dementia should have a safe environment, but access should not be unnecessarily restricted.

👉 Safety measures should focus on supervision, alarms, and removing hazards rather than confinement.

❌ "I will encourage walking alone outside for exercise each day."

👉 Exercise is beneficial for clients with dementia, but allowing the client to walk alone increases the risk of wandering, getting lost, or injury.

👉 Outdoor activities should occur with appropriate supervision.

❌ "I will provide verbal instructions for all tasks."

👉 Clients with dementia often have difficulty processing and remembering complex verbal instructions.

👉 Teaching should use simple, short instructions, demonstrations, visual cues, and step-by-step guidance.

👉 Keeping padded side rails up is an important seizure precaution because it protects the client from injury during seizure activity.

👉 During a seizure, the client may have uncontrolled movements, loss of consciousness, and sudden jerking, increasing the risk of hitting the bed rails or surrounding objects.

👉 Padding the side rails helps reduce the chance of trauma, bruising, and fractures while allowing the seizure to occur naturally.

👉 The nurse should also maintain additional safety measures, including:

Keeping the bed in a low position

Removing nearby hazardous objects

Having oxygen and suction equipment available

Turning the client to the side after the seizure to maintain airway clearance

👉 The goal of seizure precautions is to prevent injury and maintain safety, not to stop the seizure.

👉 Therefore, padded side rails are the appropriate nursing intervention.

❌ Place the bed in high Fowler's

👉 High Fowler's position is not recommended for seizure precautions because it increases the risk of the client sliding or falling during seizure activity.

👉 The bed should generally remain low and safe to reduce injury risk.

❌ Restrain limbs during a seizure

👉 The nurse should never restrain the client's limbs during a seizure.

👉 Restraining movement can cause injuries such as fractures, muscle tears, or joint damage.

👉 The nurse should protect the client from injury while allowing the seizure to run its course.

❌ Insert oral airway

👉 An oral airway should not be inserted during an active seizure.

👉 Attempting to place an object in the mouth can cause dental injury, airway trauma, or aspiration risk.

👉 The nurse should maintain airway safety by positioning the client appropriately and using suction when needed.

👉 After a total laryngectomy, the client has a permanent airway through the tracheostomy because the larynx has been removed.

👉 In the immediate postoperative period, the priority is maintaining a patent airway.

👉 A new tracheostomy is at high risk for mucus accumulation, airway obstruction, and ineffective clearance of secretions because the normal airway humidification and filtering functions have been altered.

👉 Suctioning the tracheostomy removes secretions and maintains airway patency, allowing adequate oxygen exchange.

👉 The nurse should assess respiratory status, including:

Breath sounds

Oxygen saturation

Respiratory effort

Amount and characteristics of secretions

👉 Airway management follows the ABC priority framework (Airway, Breathing, Circulation), making suctioning the first priority when airway obstruction from secretions is a concern.

👉 Therefore, suctioning the tracheostomy is the priority postoperative action.

❌ Change the inner cannula

👉 Changing the inner cannula may be necessary as part of routine tracheostomy care, but it is not the first priority immediately after surgery.

👉 Airway assessment and clearing secretions take priority before routine maintenance tasks.

❌ Encourage oral fluids

👉 A client with a total laryngectomy may have swallowing difficulties and is often kept NPO initially until swallowing ability is evaluated.

👉 Encouraging oral fluids too early increases the risk of complications such as aspiration or leakage at the surgical site.

❌ Provide oral care

👉 Oral care is important for comfort and infection prevention, but it does not address the immediate priority of maintaining the airway.

👉 Airway patency must be ensured before comfort measures.