Nursing Elites

1. A nurse is caring for a client who has a prescription for clozapine. Which of the following laboratory values should the nurse monitor?

• A. Monitor blood glucose levels
• B. Monitor WBC count
• C. Monitor platelet count
• D. Monitor hemoglobin levels

Correct answer: B

Rationale: The correct answer is to monitor the WBC count. Clozapine can cause agranulocytosis, a severe decrease in WBC count, which can increase the risk of infection. Monitoring the WBC count is essential to detect this potentially life-threatening condition early. Monitoring blood glucose levels (Choice A) is not directly related to clozapine use. Platelet count (Choice C) and hemoglobin levels (Choice D) are not typically affected by clozapine and are not the priority for monitoring in this case.

2. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

• A. Provide reality orientation throughout the day.
• B. Limit the client's choices to prevent decision fatigue.
• C. Encourage the client to participate in group therapy.
• D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

3. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

• A. Massage the injection site after administration.
• B. Administer the medication intramuscularly.
• C. Inject the medication into the client's abdomen.
• D. Inject the medication into the deltoid muscle.

Correct answer: C

Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously, not intramuscularly. Massaging the injection site after administration is not recommended as it can cause bruising or discomfort. Injecting the medication into the deltoid muscle is also incorrect because enoxaparin should be given in areas of adipose tissue, such as the abdomen, to ensure proper absorption and effectiveness.

4. A client with osteoporosis is being taught by a nurse how to prevent further bone loss. Which of the following instructions should the nurse include?

• A. Take a calcium supplement daily.
• B. Perform weight-bearing exercises.
• C. Avoid weight-bearing exercises.
• D. Limit intake of high-phosphorus foods.

Correct answer: B

Rationale: The correct answer is B: Perform weight-bearing exercises. Weight-bearing exercises are essential for preventing further bone loss and improving bone density in clients with osteoporosis. Calcium supplements alone may not be sufficient to prevent bone loss without adequate physical activity. Option C, 'Avoid weight-bearing exercises,' is incorrect as these exercises are beneficial for bone health. Option D, 'Limit intake of high-phosphorus foods,' is not directly related to preventing further bone loss in osteoporosis.

5. 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.

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