Nursing Elites

1. A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?

• A. Administer an epinephrine injection
• B. Call for immediate medical help
• C. Monitor airway, breathing, and circulation
• D. All of the above

Correct answer: A

Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.

2. A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?

• A. Check blood pressure
• B. Assess heart rate
• C. Monitor respiratory rate
• D. Measure oxygen saturation

Correct answer: B

Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.

3. The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?

• A. Perform hand hygiene before and after handling the catheter
• B. Change the catheter every 72 hours
• C. Apply antibiotic ointment at the insertion site
• D. Irrigate the catheter daily

Correct answer: A

Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.

4. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

• A. Remove the catheter and apply direct pressure for 5 minutes.
• B. Initiate intravenous fluids as prescribed.
• C. Secure the catheter using aseptic technique.
• D. Notify the healthcare provider of the need to reposition the catheter.

Correct answer: B

Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.

5. A client with a history of chronic kidney disease (CKD) is being discharged with a prescription for epoetin alfa (Epogen). What should the nurse include in the discharge teaching?

• A. Take this medication on an empty stomach.
• B. Monitor your blood pressure regularly.
• C. Expect to feel better immediately.
• D. Avoid foods high in potassium.

Correct answer: B

Rationale: The correct answer is B: 'Monitor your blood pressure regularly.' Epoetin alfa (Epogen) can lead to hypertension as a side effect, so it is essential for clients with CKD to monitor their blood pressure regularly. Choice A is incorrect because epoetin alfa does not need to be taken on an empty stomach. Choice C is incorrect because the client should not expect immediate improvement upon starting the medication. Choice D is incorrect because while monitoring potassium intake is important in CKD, the question specifically pertains to epoetin alfa and its side effects, not potassium intake.

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