Nursing Elites

1. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?

• A. Place the client on cardiac monitoring
• B. Monitor the client's oxygen saturation level
• C. Provide standby assistance when getting out of bed
• D. Encourage foods high in potassium

Correct answer: C

Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.

2. A client is in the transition phase of labor. Which of the following actions should the nurse take?

• A. Assist the client to void every 3 hours
• B. Monitor contractions every 30 minutes
• C. Place the client in a lithotomy position
• D. Encourage the client to use a pant-blow breathing pattern

Correct answer: D

Rationale: Encouraging the client to use a pant-blow breathing pattern is crucial during the transition phase of labor. This phase is characterized by intense contractions and emotional responses. Pant-blow breathing helps manage pain and anxiety, providing comfort and support to the client. Voiding every 3 hours is not specific to the transition phase and may not address immediate needs. Monitoring contractions every 30 minutes is important but may not be as directly beneficial as focusing on coping mechanisms like breathing techniques. Placing the client in a lithotomy position is generally not recommended during the transition phase as it can impede progress and comfort.

3. A 65-year-old client is taking methylprednisolone. What pharmacological action should the nurse expect with this therapy?

• A. Suppression of beta2 receptors.
• B. Suppression of airway mucus production.
• C. Fortification of bones.
• D. Suppression of candidiasis.

Correct answer: B

Rationale: The correct answer is B: 'Suppression of airway mucus production.' Methylprednisolone, a corticosteroid, is known to suppress airway mucus production. While corticosteroids can enhance the responsiveness of beta2 receptors, they are not directly involved in the suppression of these receptors (Choice A). Corticosteroids can lead to adverse effects such as bone loss, rather than fortification of bones (Choice C). They can also increase the risk of infections like candidiasis but do not directly suppress it (Choice D). Therefore, the most expected pharmacological action of methylprednisolone therapy is the suppression of airway mucus production.

4. A community nurse is instructing a group of high school students about the transmission of hepatitis A. Which mode of transmission should the nurse include in the teaching?

• A. Sexual contact
• B. Airborne droplets
• C. Fecal-oral
• D. Bloodborne

Correct answer: C

Rationale: The correct answer is C: Fecal-oral. Hepatitis A is primarily transmitted through the fecal-oral route, often from consuming contaminated food or water. Choice A, sexual contact, is not a typical mode of transmission for hepatitis A. Choice B, airborne droplets, is more characteristic of diseases like influenza or tuberculosis. Choice D, bloodborne transmission, is more relevant to hepatitis B and C, not hepatitis A.

5. A healthcare professional is assessing a client with a history of heart disease. Which of the following findings should the healthcare professional monitor?

• A. Blood pressure
• B. Weight
• C. Heart rhythm
• D. All of the above

Correct answer: D

Rationale: Monitoring blood pressure, weight, and heart rhythm is crucial in clients with a history of heart disease as these parameters can indicate changes in the cardiovascular status. Changes in blood pressure can signify heart strain, weight fluctuations can be related to fluid retention or heart failure, and irregular heart rhythm can indicate arrhythmias or other cardiac issues. Monitoring all these parameters comprehensively allows for early detection of potential complications and timely intervention. Therefore, selecting 'All of the above' is the correct choice as it encompasses all the essential parameters for monitoring in clients with heart disease. Choices A, B, and C are incorrect as monitoring only one or two of these parameters may lead to missing important changes in the client's condition.

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