Nursing Elites

1. A nurse is caring for a client who has congestive heart failure. Which of the following prescriptions from the provider should the nurse anticipate?

• A. Call the provider if the client’s respiratory rate is less than 18/min
• B. Administer 500 mL IV bolus of 0.9% sodium chloride over 1 hour
• C. Administer enalapril 2.5 mg PO twice daily
• D. Call the provider if the client’s pulse rate is less than 80/min

Correct answer: C

Rationale: The correct answer is C. Enalapril is an ACE inhibitor commonly prescribed for clients with congestive heart failure to help reduce blood pressure and fluid overload. Option A is incorrect as in congestive heart failure, a lower respiratory rate could be a sign of worsening condition and needs immediate attention rather than waiting to call the provider. Option B is incorrect as administering a large IV bolus of sodium chloride could exacerbate fluid overload in a client with heart failure. Option D is incorrect as a pulse rate lower than 80/min may not necessarily indicate a problem in a client with congestive heart failure.

2. A healthcare professional is caring for a client receiving potassium-sparing diuretics. Which of the following should the healthcare professional monitor?

• A. Hypokalemia
• B. Hyperkalemia
• C. Hypoglycemia
• D. Hyponatremia

Correct answer: B

Rationale: Corrected Rationale: When a client is receiving potassium-sparing diuretics, the healthcare professional should monitor for hyperkalemia. Potassium-sparing diuretics can cause potassium retention, leading to elevated potassium levels in the blood. Monitoring potassium levels is crucial to prevent hyperkalemia-related complications such as cardiac arrhythmias. Choices A, C, and D are incorrect because potassium-sparing diuretics typically do not cause hypokalemia, hypoglycemia, or hyponatremia.

3. A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.

4. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.

• A. Intact skin with nonblanchable redness (Stage 1)
• B. Full-thickness tissue loss with subQ damage (Stage 3)
• C. Partial-thickness skin loss involving the epidermis and dermis
• D. Full-thickness tissue loss with damage to muscle or bone (Stage 4)

Correct answer: C

Rationale: The correct answer is C. Stage 2 ulcers involve partial-thickness skin loss with visible and superficial damage, which may appear as an abrasion, blister, or shallow crater. Choice A describes a Stage 1 pressure ulcer characterized by intact skin with nonblanchable redness. Choice B describes a Stage 3 pressure ulcer with full-thickness tissue loss and damage to the subcutaneous tissue. Choice D is indicative of a Stage 4 pressure ulcer, involving full-thickness tissue loss with damage extending to muscle or bone.

5. A nurse is providing discharge instructions for a client after surgery. Which of the following should be included?

• A. Resume normal activities immediately
• B. Monitor for signs of infection
• C. Avoid all physical activity for 1 month
• D. Take pain medications only as needed

Correct answer: B

Rationale: The correct answer is B: 'Monitor for signs of infection.' After surgery, it is essential for clients to watch for signs of infection, such as increased redness, swelling, or drainage at the incision site. Choice A is incorrect because resuming normal activities immediately after surgery can be harmful. Choice C is incorrect as complete avoidance of physical activity for a month is typically not necessary and can lead to complications like blood clots. Choice D is incorrect as taking pain medications only as needed may not provide adequate pain management post-surgery.

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