Nursing Elites

1. A client with hypocalcemia is receiving calcium gluconate. What assessment finding requires immediate intervention?

• A. Decreased deep tendon reflexes.
• B. Wheezing and stridor.
• C. Decreased bowel sounds.
• D. Positive Chvostek's sign.

Correct answer: B

Rationale: Wheezing and stridor may indicate a severe allergic reaction to calcium gluconate, such as anaphylaxis, which requires immediate intervention. While hypocalcemia can present with decreased deep tendon reflexes and positive Chvostek's sign, these findings do not indicate an immediate life-threatening situation. Decreased bowel sounds are not directly related to a severe reaction to calcium gluconate and do not require immediate intervention.

2. A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?

• A. Hemoglobin level
• B. Platelet count
• C. Activated partial thromboplastin time (aPTT)
• D. Prothrombin time (PT)

Correct answer: B

Rationale: The correct answer is B: Platelet count. Enoxaparin can cause heparin-induced thrombocytopenia (HIT), making it crucial to monitor the platelet count for signs of thrombocytopenia. Monitoring the platelet count helps in early detection of this serious adverse effect. Choices A, C, and D are less relevant in this context. Hemoglobin level checks are more indicative of bleeding issues rather than thrombocytopenia caused by enoxaparin. Activated partial thromboplastin time (aPTT) and prothrombin time (PT) are less impacted by enoxaparin and are not typically used to monitor for HIT.

3. A client is diagnosed with tuberculosis and is placed on isoniazid (INH) and rifampin (Rifadin). The nurse should emphasize the importance of

• A. Daily use of a bronchodilator
• B. The importance of taking medication as prescribed
• C. Decreasing salt intake
• D. Avoidance of direct sunlight

Correct answer: B

Rationale: The correct answer is B: The importance of taking medication as prescribed. In the treatment of tuberculosis, adherence to the prescribed medication regimen is crucial to effectively manage the infection and prevent the development of drug resistance. Choices A, C, and D are incorrect because bronchodilators, salt intake, and sunlight exposure are not directly related to the treatment of tuberculosis with isoniazid and rifampin.

4. A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?

• A. Administer an antihistamine as prescribed.
• B. Stop the infusion and notify the healthcare provider.
• C. Slow the infusion rate and monitor the client.
• D. Administer epinephrine subcutaneously.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.

5. The nurse is preparing a discharge teaching plan for a liver transplant client. Which instruction is most important to include in this plan?

• A. Ensure daily follow-up with the healthcare provider
• B. Take immunosuppressant medications as prescribed
• C. Avoid crowds for the first two months after surgery
• D. Return to work in three months

Correct answer: B

Rationale: The most critical instruction to include in the discharge teaching plan for a liver transplant client is to take immunosuppressant medications as prescribed. This is vital to prevent organ rejection and ensure the success of the transplant. While ensuring daily follow-up with the healthcare provider is important for monitoring progress, avoiding crowds for the first two months after surgery helps reduce the risk of infections but is not as crucial as medication adherence. Returning to work in three months is a consideration but not the most important aspect immediately post-transplant.

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