Nursing Elites

1. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include?

• 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 action the nurse should include for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent constipation, straining, and subsequent bleeding, which is crucial for clients with thrombocytopenia. Encouraging the client to floss daily (Choice A) is important for oral hygiene but not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems to reduce the risk of foodborne illnesses but is not directly related to thrombocytopenia management.

2. A healthcare professional is caring for a client who has a new prescription for metformin. Which of the following laboratory results should the healthcare professional review before administering the medication?

• A. Potassium
• B. Serum creatinine
• C. Sodium
• D. Hemoglobin A1C

Correct answer: B

Rationale: Correct Answer: The healthcare professional should review serum creatinine levels before administering metformin to assess kidney function. Metformin is excreted by the kidneys, and checking serum creatinine helps prevent lactic acidosis, a potential side effect in individuals with impaired renal function. Choice A: Potassium levels are not directly related to the administration of metformin. While monitoring potassium levels is important for some medications, it is not the priority when initiating metformin. Choice C: Sodium levels are not typically assessed specifically before starting metformin. It is not a routine lab test required prior to metformin administration. Choice D: Hemoglobin A1C reflects long-term blood sugar control and is not a lab test that needs to be reviewed before initiating metformin. It is used to monitor diabetes management over time, not for immediate medication administration considerations.

3. A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse take?

• A. Place the client in a high-Fowler's position
• B. Assist the client to the left Sims' position
• C. Insert the enema tubing 2.5 cm (1 in) into the rectum
• D. Lubricate the tip of the enema tubing with petroleum jelly

Correct answer: B

Rationale: The correct answer is to assist the client to the left Sims' position when administering an enema. This position helps facilitate the flow of the enema solution into the rectum. Placing the client in a high-Fowler's position (Choice A) is not ideal for administering an enema. Inserting the enema tubing 2.5 cm (1 in) into the rectum (Choice C) is incorrect as it should be inserted 7.5-10 cm (3-4 in) for an adult. Lubricating the tip of the enema tubing with petroleum jelly (Choice D) is a correct step to ease insertion but is not the most critical action among the choices provided.

4. A client who has glaucoma and a new prescription for timolol eyedrops is receiving teaching from a nurse. Which of the following statements indicates an understanding of the teaching?

• A. I will place the eye drops in the center of my eye.
• B. I will place pressure on the corner of my eye after using the drops.
• C. I should expect my tears to turn red after using the drops.
• D. I should expect the drops to appear cloudy.

Correct answer: B

Rationale: The correct answer is B because placing pressure on the corner of the eye after using the drops helps in better absorption. Option A is incorrect because eye drops should be placed in the conjunctival sac, not the center of the eye. Option C is incorrect because tears turning red is not an expected outcome of using timolol eyedrops. Option D is incorrect because timolol eyedrops should not appear cloudy.

5. What is the priority nursing intervention for a patient experiencing an acute asthma attack?

• A. Administer bronchodilators
• B. Monitor oxygen saturation
• C. Provide supplemental oxygen
• D. Start IV fluids

Correct answer: A

Rationale: The correct answer is to administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve airflow. Bronchodilators like albuterol are crucial in providing immediate relief to the patient. Monitoring oxygen saturation (choice B) is important but administering bronchodilators takes precedence in managing the acute attack. Providing supplemental oxygen (choice C) may be necessary but addressing the airway obstruction with bronchodilators is the priority. Starting IV fluids (choice D) is not the priority in an acute asthma attack unless specifically indicated for other reasons such as dehydration.

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