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 nurse is teaching a client about the use of pantoprazole. Which of the following should be included?

• A. It should be taken on an empty stomach
• B. It reduces stomach acid production
• C. It can cause headache
• D. It should not be used with other antacids

Correct answer: C

Rationale: The correct information to include when teaching a client about pantoprazole is that it can cause headaches. Option A is incorrect because pantoprazole is usually taken before meals. Option B is not necessary information for the client to know. Option D is not directly related to the side effects of pantoprazole.

3. A nurse is assessing a client who has a femur fracture and is in skeletal traction. Which of the following findings should the nurse report to the provider?

• A. Clear fluid drainage from the pin sites
• B. Client reporting intermittent muscle spasms
• C. Client reporting severe pain despite receiving analgesics
• D. The traction weights are hanging freely

Correct answer: C

Rationale: The correct answer is C. Severe pain that is not relieved by analgesics may indicate neurovascular compromise or other complications and requires immediate attention by the provider. Choices A, B, and D are incorrect because clear fluid drainage from the pin sites is expected in skeletal traction, intermittent muscle spasms are common in this situation, and traction weights hanging freely indicate proper traction alignment.

4. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.

• A. Hepatotoxicity
• B. Constipation
• C. Infusion reaction
• D. Immunosuppression

Correct answer: C

Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.

5. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?

• A. Applesauce
• B. Mashed potatoes
• C. Orange slices
• D. Soft bread

Correct answer: C

Rationale: The correct answer is C: Orange slices. Orange slices contain membranes that are difficult to swallow, which can pose a risk to clients on a mechanical soft diet. This type of diet is designed for individuals who have difficulty chewing or swallowing. Choices A, B, and D are suitable for a mechanical soft diet as they are soft in texture and easy to chew and swallow.

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