Nursing Elites

1. A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse report to the provider?

• A. Crackles in the lung bases
• B. Oxygen saturation of 95%
• C. Heart rate of 88/min
• D. Frequent productive cough

Correct answer: A

Rationale: The correct answer is A: Crackles in the lung bases. In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, suggesting worsening respiratory status. This finding should be reported to the provider for further evaluation and management. Choice B, an oxygen saturation of 95%, is within the normal range and does not require immediate reporting. Choice C, a heart rate of 88/min, is also within normal limits and does not indicate an urgent need for intervention. Choice D, a frequent productive cough, is a common symptom in pneumonia and may not require immediate reporting unless it is severe or worsening. Therefore, crackles in the lung bases are the most concerning finding that warrants prompt attention.

2. A client who has a new diagnosis of hypertension is being taught about dietary modifications by a nurse. Which of the following instructions should the nurse include?

• A. Limit fluid intake to 2 liters per day.
• B. Increase your intake of whole grains.
• C. Eat 3 large meals daily.
• D. Consume foods high in potassium.

Correct answer: B

Rationale: The correct answer is B: 'Increase your intake of whole grains.' Whole grains are beneficial for individuals with hypertension as they can help promote heart health. Whole grains are high in fiber, which can help lower blood pressure. Option A is incorrect as fluid intake should be adequate but not restricted to 2 liters per day. Option C is incorrect as it is recommended to have smaller, more frequent meals rather than 3 large meals to help manage hypertension. Option D is incorrect; although foods high in potassium can be beneficial for hypertension, the most appropriate dietary modification to include in this scenario is increasing whole grain intake.

3. A nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the nurse take?

• A. Check for residual feeding contents.
• B. Administer the feeding through a large-bore syringe.
• C. Flush the tube with 10 mL of water after feeding.
• D. Administer the feeding at room temperature.

Correct answer: C

Rationale: The correct action for the nurse to take when preparing to administer an intermittent enteral feeding through a nasogastric tube is to flush the tube with 10 mL of water after feeding. This helps maintain tube patency and prevent clogging. Choice A, checking for residual feeding contents, is not the immediate action to take before administering the feeding. Choice B, administering the feeding through a large-bore syringe, is not the recommended method for administering enteral feedings. Choice D, administering the feeding at room temperature, is important but not the immediate action related to tube maintenance.

4. A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?

• A. Withhold the next dose.
• B. Increase the dosage.
• C. Discontinue the medication.
• D. Administer the medication.

Correct answer: D

Rationale: Administering the medication is appropriate for a stable lithium level of 0.8 mEq/L. A level of 0.8 mEq/L falls within the therapeutic range for lithium, indicating that the client is receiving an adequate dose to maintain therapeutic effects. Withholding the next dose, increasing the dosage, or discontinuing the medication would not be indicated at this lithium level as it is within the desired range for therapeutic benefit. Therefore, the correct action would be to continue administering the medication to ensure the client maintains the therapeutic level of lithium.

5. A nurse is teaching a client who has a new prescription for captopril. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. Take this medication 1 hour before meals.
• C. Avoid potassium supplements while taking this medication.
• D. You may experience a persistent, dry cough while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Captopril is known to cause a persistent, dry cough as a common side effect. Instructing the client about this potential side effect is crucial for their awareness. Choices A and B are incorrect because captopril is usually taken on an empty stomach. Choice C is incorrect because captopril can lead to hyperkalemia, so potassium supplements may be necessary in some cases.

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