Nursing Elites

1. A client is receiving vancomycin. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Serum creatinine
• C. INR levels
• D. Liver function tests

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Vancomycin is known to be nephrotoxic, meaning it can cause kidney damage. Monitoring serum creatinine levels is essential to assess kidney function and detect any signs of nephrotoxicity. Blood glucose levels (choice A) are not directly affected by vancomycin. INR levels (choice C) are typically monitored for clients on anticoagulants, not vancomycin. Liver function tests (choice D) are not primarily affected by vancomycin use; kidney function is of greater concern.

2. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client’s skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder frequently to the client’s skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client’s skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because inspecting the pin site every 4 hours is necessary but not the priority in this case. Choice C is incorrect as it is not essential for two personnel to hold the halo device during repositioning. Choice D is incorrect because applying powder frequently can actually increase the risk of skin issues by clogging pores and causing irritation.

3. A nurse is teaching a client with mild persistent asthma about montelukast. Which statement by the client indicates understanding?

• A. I will use this for asthma attacks.
• B. I should take this before exercise.
• C. This medication will decrease swelling and mucus production.
• D. I can stop this medication after 10 days.

Correct answer: C

Rationale: Montelukast is a leukotriene receptor antagonist that helps reduce swelling and mucus production in the airways, making it useful for long-term asthma management.

4. A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high-calorie, low-protein diet. Which of the following meal selections is appropriate for this client?

• A. Scrambled eggs, bacon, and pancakes
• B. Grilled cheese sandwich, potato chips, chocolate pudding
• C. Steak, French fries, corn
• D. Chicken breast, mashed potatoes, spinach

Correct answer: D

Rationale: The correct answer is D: Chicken breast provides a low-fat protein source, and mashed potatoes and spinach provide high-calorie nutrients suitable for managing liver failure. Option A (Scrambled eggs, bacon, and pancakes) is high in protein, which is not suitable for a low-protein diet. Option B (Grilled cheese sandwich, potato chips, chocolate pudding) contains high protein and may not be appropriate for the client. Option C (Steak, French fries, corn) is high in protein and fat, which are not recommended for this client's dietary requirements.

5. A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?

• A. My family can make decisions if I am unable to.
• B. I have a living will that outlines my wishes when I am unable to make a decision.
• C. I can write down my wishes, but they aren't legally binding.
• D. I don't need to worry about this until I’m critically ill.

Correct answer: B

Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.

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