Nursing Elites

1. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

• A. Fruit-flavored yogurt
• B. Cheese and crackers
• C. Cold cereal with skim milk
• D. Toasted wheat bread and jelly

Correct answer: D

Rationale: The correct answer is D: Toasted wheat bread and jelly. Dairy products decrease the effect of tetracycline, so the nurse should instruct the client to avoid them. Toast, which contains no dairy products, may help decrease gastrointestinal symptoms. Choices A, B, and C contain dairy products, which should be avoided when taking tetracycline.

2. A client with a history of congestive heart failure is admitted with shortness of breath. Which nursing intervention should the nurse implement first?

• A. Elevate the head of the bed.
• B. Administer prescribed diuretic therapy.
• C. Monitor the client's oxygen saturation.
• D. Assess the client's level of consciousness.

Correct answer: A

Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed is crucial in improving oxygenation in clients with congestive heart failure and shortness of breath by reducing venous return to the heart and decreasing fluid overload in the lungs. This intervention helps to alleviate the client's breathing difficulty. Administering diuretic therapy (Choice B) may be necessary but is not the initial priority. Monitoring oxygen saturation (Choice C) is important but should come after ensuring proper positioning. Assessing the client's level of consciousness (Choice D) is essential but is not the first intervention needed for a client experiencing respiratory distress.

3. The nurse is caring for a client who is 2 days postoperative following abdominal surgery. The client reports pain at the incision site and a small amount of purulent drainage is noted. What is the most appropriate nursing action?

• A. Apply a sterile dressing to the incision.
• B. Reinforce the dressing and document the findings.
• C. Remove the dressing and assess the incision site.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct answer is to notify the healthcare provider. Purulent drainage at the incision site is concerning as it may indicate an infection. The healthcare provider needs to be informed promptly to initiate appropriate treatment. Applying a sterile dressing (Choice A) may not address the underlying issue of infection. Reinforcing the dressing and documenting findings (Choice B) is important but should be preceded by notifying the healthcare provider. Removing the dressing and assessing the incision site (Choice C) may disturb the area and should be done under the guidance of the healthcare provider.

4. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: Subcutaneous emphysema is the assessment finding that requires immediate intervention in a client with a chest tube following a pneumothorax. Subcutaneous emphysema can indicate a pneumothorax recurrence or air leak, which can compromise respiratory function and lead to serious complications. Oxygen saturation of 94% may be concerning but does not require immediate intervention as it is still within an acceptable range. Crepitus around the insertion site is common after chest tube placement and may not always indicate a problem. A blood pressure of 110/70 mmHg is within normal limits and does not require immediate intervention in this context.

5. The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?

• A. Initiation of the impulses from a location outside the SA node
• B. Inability of the SA node to initiate an impulse at the normal rate
• C. Increased conduction time from the SA node to the AV junction
• D. Interference with the conduction through one or both ventricles

Correct answer: C

Rationale: When the PR interval is prolonged, it signifies an increased conduction time from the SA node through the AV junction. This finding is characteristic of a first-degree heart block where there is a delay in the electrical conduction at the level of the AV node. Choices A, B, and D are incorrect as they do not accurately reflect the significance of a prolonged PR interval.

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