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 provider is caring for four clients. Which of the following tasks can the healthcare provider delegate to an assistive personnel?

• A. Perform chest compressions during cardiac resuscitation
• B. Perform a dressing change for a new amputee
• C. Assess the effectiveness of antiemetic medication
• D. Provide discharge instructions

Correct answer: A

Rationale: Performing chest compressions during cardiac resuscitation is a critical life-saving intervention that can be delegated to an assistive personnel during an emergency. This task requires immediate action and basic training, making it appropriate for delegation. Performing a dressing change for a new amputee involves specialized knowledge and skills, typically performed by licensed healthcare providers. Assessing the effectiveness of medication requires critical thinking and decision-making skills that are within the scope of a licensed healthcare provider. Providing discharge instructions involves educating the patient on post-discharge care and follow-up, which is typically done by a healthcare provider to ensure clear communication and understanding.

3. A patient is scheduled for cataract surgery but decides to cancel, stating 'I see just fine.' Which of the following responses should the nurse make?

• A. That’s not a good idea; the surgery is necessary
• B. Share with me more about the thoughts that are concerning you
• C. You should trust your doctor’s advice
• D. You can always reschedule the surgery later

Correct answer: B

Rationale: The correct response is to encourage the patient to share more about their concerns. This approach helps the nurse understand the patient's perspective and allows for a supportive discussion. Choice A is dismissive and does not address the patient's feelings. Choice C may undermine the patient's autonomy and decision-making. Choice D suggests delaying without addressing the patient's current decision.

4. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

5. A nurse is caring for a client with hepatic encephalopathy. Which food selection indicates an understanding of dietary teaching?

• A. Cottage cheese
• B. Tuna salad
• C. Rice with black beans
• D. Three-egg omelet

Correct answer: C

Rationale: The correct answer is C: 'Rice with black beans.' Clients with hepatic encephalopathy should limit animal proteins due to their high ammonia content, which can exacerbate symptoms. Plant-based proteins like beans are preferred as they help reduce ammonia levels. Choices A, B, and D contain animal proteins that are not ideal for clients with hepatic encephalopathy.

Similar Questions