Nursing Elites

1. A nurse is caring for four clients. Which of the following client data should the nurse report to the provider?

• A. Client who has pleurisy and reports pain of 6 on a scale of 0 to 10
• B. Client with 110 mL of serosanguineous fluid from a Jackson Pratt drain within the first 24 hours after surgery
• C. Client who is 4 hours postoperative and has a heart rate of 98 bpm
• D. Client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

Correct answer: D

Rationale: An absolute neutrophil count of 75/mm3 indicates severe neutropenia, which puts the client at high risk of infection and requires immediate intervention. Neutropenia increases the susceptibility to infections due to a significant decrease in neutrophils, which are essential for fighting off bacteria and other pathogens. Reporting this critical lab value promptly to the provider is essential to ensure appropriate interventions are initiated to prevent life-threatening infections. Choices A, B, and C do not present immediate life-threatening conditions that require urgent reporting to the provider.

2. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care?

• A. Initiate droplet precautions
• B. Assist the client to a supine position
• C. Perform Glasgow Coma Scale assessment every 24 hours
• D. Recommend prophylactic acyclovir for the client’s family

Correct answer: A

Rationale: The correct answer is A: 'Initiate droplet precautions.' Bacterial meningitis requires droplet precautions to prevent the spread of infection, as the bacteria can be transmitted through respiratory secretions. Choice B is incorrect because assisting the client to a supine position is not specific to the care of a client with bacterial meningitis and may not be appropriate for all clients. Choice C is incorrect because while performing Glasgow Coma Scale assessments is important in managing clients with neurological conditions, it is not directly related to preventing the spread of bacterial meningitis. Choice D is incorrect because recommending prophylactic acyclovir for the client's family is not a standard precautionary measure for preventing the spread of bacterial meningitis.

3. A healthcare provider is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the healthcare provider use?

• A. A wheelchair
• B. A stand-assist lift
• C. A transfer belt
• D. A slide board

Correct answer: B

Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This device provides support and assistance for the client to stand up and transfer safely. Choice A, a wheelchair, is not designed for this purpose and is used for mobility. Choice C, a transfer belt, is helpful for providing stability during transfers but may not be sufficient for a client with partial weight-bearing. Choice D, a slide board, is more suitable for transferring clients who are unable to bear weight and need assistance for lateral transfers.

4. A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?

• A. Change positions slowly and lie down if dizziness occurs
• B. There is no need to avoid normal activities
• C. Avoid dairy products while taking this medication
• D. Do not eat green leafy vegetables

Correct answer: A

Rationale: The correct answer is A. Doxazosin can cause first-dose orthostatic hypotension, which may lead to dizziness or fainting when the client stands up too quickly. The nurse should advise the client to change positions slowly and lie down if dizziness occurs to prevent falls and other injuries. Choice B is incorrect because while the client can continue normal activities, caution should be taken with position changes. Choice C is incorrect as doxazosin does not interact with dairy products. Choice D is incorrect as there is no need to avoid green leafy vegetables specifically while taking doxazosin.

5. 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.

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