Nursing Elites

1. A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

• A. Lower the right arm below the level of the heart.
• B. Elevate the right arm on a pillow.
• C. Apply a tourniquet above the insertion site.
• D. Apply a warm compress to the insertion site.

Correct answer: A

Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.

2. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor (ACEI). Which instruction should the nurse include in the medication teaching plan?

• A. Increase intake of potassium-rich foods
• B. Report increased bruising or bleeding
• C. Stop medication if a cough develops
• D. Limit intake of leafy green vegetables

Correct answer: B

Rationale: The correct instruction for the nurse to include in the medication teaching plan for a client receiving enalapril, an ACE inhibitor, is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which can lead to an increased risk of bruising and bleeding. Monitoring and reporting these symptoms promptly are essential to prevent complications. Choices A, C, and D are incorrect because increasing potassium-rich foods, stopping medication if a cough develops, and limiting intake of leafy green vegetables are not directly related to the common side effects or actions of ACE inhibitors.

3. After checking the fingerstick glucose at 1630, what action should be implemented?

• A. Notify the healthcare provider.
• B. Administer 8 units of insulin aspart SubQ.
• C. Give an IV bolus of Dextrose 50% 50 ml.
• D. Perform quality control on the glucometer.

Correct answer: B

Rationale: Administering insulin aspart (rapid-acting insulin) is the appropriate action to manage the elevated glucose level of 1630. Choice A, notifying the healthcare provider, is not the immediate action needed for this glucose level. Choice C, giving an IV bolus of Dextrose 50%, would exacerbate hyperglycemia instead of treating it. Choice D, performing quality control on the glucometer, is not relevant to the management of the patient's glucose level at this time.

4. A client with chronic heart failure is admitted with shortness of breath and a new onset of confusion. Which intervention should the nurse implement first?

• A. Obtain a neurological assessment.
• B. Administer oxygen therapy.
• C. Monitor the client's urine output.
• D. Obtain an electrocardiogram (ECG).

Correct answer: A

Rationale: The correct answer is to obtain a neurological assessment. In a client with chronic heart failure presenting with confusion, the priority is to assess neurological status to rule out potential causes such as hypoxia or other complications. Administering oxygen therapy (Choice B) is important but assessing the neurological status takes precedence in this scenario. Monitoring urine output (Choice C) and obtaining an ECG (Choice D) may be necessary but are not the initial priority when a client presents with confusion alongside shortness of breath.

5. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?

• A. INR of 3.5
• B. Prothrombin time (PT) of 15 seconds
• C. Headache
• D. Blood pressure of 140/90 mmHg

Correct answer: C

Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.

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