Nursing Elites

1. A client receiving chemotherapy reports severe nausea. What should the nurse implement first?

• A. Administer an antiemetic as prescribed.
• B. Offer the client small, frequent meals.
• C. Provide the client with crackers and water.
• D. Encourage the client to eat a bland diet.

Correct answer: A

Rationale: The correct answer is A: Administer an antiemetic as prescribed. When a client receiving chemotherapy reports severe nausea, the priority action is to administer an antiemetic medication as prescribed. Antiemetics help alleviate nausea and prevent complications associated with chemotherapy, such as dehydration and malnutrition. Options B, C, and D focus on dietary interventions which can be helpful but addressing the severe nausea with antiemetic medication takes precedence to provide immediate relief and ensure the client's comfort and well-being.

2. A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?

• A. Notify the healthcare provider of the client's distress.
• B. Auscultate the client's lung sounds and oxygen saturation.
• C. Determine if the client is experiencing anxiety.
• D. Assess the oxygen delivery system.

Correct answer: B

Rationale: The correct action for the nurse to implement first is to auscultate the client's lung sounds and oxygen saturation. This helps in assessing the respiratory status of the client, which is crucial in managing COPD and emphysema exacerbations. Checking for any abnormalities in lung sounds and monitoring oxygen saturation levels can provide important information for immediate intervention. Option A is not the first action to take in this situation as directly assessing the client's respiratory status is more immediate. Option C, determining if the client is experiencing anxiety, is important but should come after assessing the physical respiratory status. Option D, assessing the oxygen delivery system, is also essential but should follow the direct assessment of the client's respiratory status.

3. A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?

• A. Report orange-colored urine as a sign of kidney dysfunction.
• B. Expect red-orange discoloration of urine as a harmless side effect.
• C. Monitor for signs of liver toxicity.
• D. Call the healthcare provider if vision changes occur.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.

4. The mother of a 2-day-old infant girl expresses concern about a 'flea bite' type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

• A. We need to monitor the rash for signs of worsening or fever
• B. Your baby may have an allergic reaction to laundry detergent
• C. This is a common newborn rash that will resolve after several days
• D. This is likely a bacterial infection requiring antibiotics

Correct answer: C

Rationale: The rash described is typical of erythema toxicum neonatorum, a common and benign newborn rash that resolves on its own within a few days. No treatment is necessary, and the nurse should reassure the mother. Choice A is incorrect as the rash is self-limiting and does not require monitoring for worsening signs or fever. Choice B is incorrect as erythema toxicum neonatorum is not caused by an allergic reaction to laundry detergent. Choice D is incorrect as this rash is not indicative of a bacterial infection that requires antibiotics.

5. A client is scheduled for a colonoscopy and has been prescribed a bowel preparation. What is the most important instruction for the nurse to provide?

• A. Eat a low-fiber diet the day before the procedure
• B. Drink clear liquids 24 hours before the procedure
• C. Take the entire bowel preparation as directed
• D. Avoid all solid foods 12 hours before the procedure

Correct answer: C

Rationale: The most important instruction for the nurse to provide to a client scheduled for a colonoscopy and prescribed a bowel preparation is to take the entire bowel preparation as directed. Completing the entire bowel preparation as prescribed is crucial to ensure the colon is properly cleansed for the colonoscopy. Incomplete bowel prep can interfere with the visualization of the colon, leading to inaccurate results. Choices A, B, and D are important but not as crucial as ensuring the complete intake of the bowel preparation for an effective procedure.

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