Nursing Elites

1. A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?

• A. Keep calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit IV exposure to light.
• D. Attach an inline filter to the IV tubing.

Correct answer: C

Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.

2. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?

• A. Productive cough with green sputum
• B. Temperature of 37.1°C (98.8°F)
• C. Crackles in the lung bases
• D. Oxygen saturation of 95%

Correct answer: C

Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.

3. A nurse is providing care to a client who has thrombocytopenia. Which of the following actions should the nurse take?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener helps prevent constipation, reduces the need for straining during bowel movements, and ultimately decreases the risk of bleeding. Choice A is incorrect as flossing daily does not directly address the issue of bleeding risk associated with thrombocytopenia. Choice B is incorrect as removing fresh flowers from the client's room is more related to the risk of infection rather than bleeding in thrombocytopenia. Choice D is incorrect as avoiding serving raw vegetables does not directly impact the risk of bleeding in clients with thrombocytopenia.

4. A nurse is assessing a client who has a history of seizure disorder and is receiving phenytoin. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Bradycardia.
• B. Ataxia.
• C. Tachycardia.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Ataxia. Ataxia, which refers to uncoordinated movements, is a common adverse effect of phenytoin, a medication used to manage seizure disorders. Bradycardia (Choice A) is not typically associated with phenytoin; instead, it may cause tachycardia (Choice C) as a side effect. Insomnia (Choice D) is not a common adverse effect of phenytoin.

5. A nurse is providing teaching to a client who is postoperative following a cataract extraction. Which of the following statements should the nurse include?

• A. You should expect to have eye pain for the first 2 days after surgery.
• B. You should bend at the waist to pick up objects from the floor.
• C. You should avoid sleeping on the side of the body that was operated on.
• D. You should wear an eye shield at night for 2 weeks.

Correct answer: D

Rationale: The correct answer is D. After cataract surgery, wearing an eye shield at night for 2 weeks is essential to protect the eye during the initial healing period. Choice A is incorrect because significant eye pain should not be expected for the first 2 days after surgery. Choice B is incorrect as bending at the waist can increase intraocular pressure, which should be avoided postoperatively. Choice C is incorrect as there is no need to avoid sleeping on the side of the body that was operated on after cataract surgery.

Similar Questions