Nursing Elites

1. A healthcare professional is preparing to administer a dose of hydrocodone. Which of the following should the healthcare professional assess first?

• A. Respiratory rate
• B. Blood pressure
• C. Pain level
• D. Heart rate

Correct answer: A

Rationale: When administering hydrocodone, a healthcare professional should assess the respiratory rate first because hydrocodone is an opioid that can lead to respiratory depression. Monitoring the respiratory rate helps to detect any signs of respiratory distress or depression early on. Assessing blood pressure, pain level, or heart rate is also important but not the priority when administering hydrocodone, as the risk of respiratory depression is a more critical concern.

2. A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?

• A. Position the client with the affected extremity higher than the heart
• B. Administer acetaminophen for pain
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.

3. While assessing four clients, which client data should be reported to the provider?

• A. Client with pleurisy who reports a pain level of 6 out of 10 when coughing
• B. Client with 110 mL of serosanguineous fluid from a JP drain
• C. Client 4 hours postoperative with a heart rate of 98 bpm
• D. Client undergoing chemotherapy with an absolute neutrophil count of 75/mm³

Correct answer: D

Rationale: An absolute neutrophil count of 75/mm³ is critically low and places the client at high risk for infection, necessitating immediate intervention. Neutropenia increases susceptibility to infections, making it essential to report this finding promptly. The other options, such as pain level in pleurisy, drainage amount from a drain, and heart rate postoperatively, are important but do not indicate an immediate life-threatening condition that requires urgent provider notification.

4. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

• A. Dry, cracked lips
• B. Bleeding gums
• C. Foul-smelling breath
• D. Red, open sores in the mouth

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

5. A nurse is preparing to administer a pneumococcal vaccine. Which of the following should the nurse verify?

• A. Client's allergy to eggs
• B. Client's current medications
• C. Client's vaccination history
• D. Client's blood pressure

Correct answer: C

Rationale: The correct answer is C: Client's vaccination history. Before administering a pneumococcal vaccine, the nurse should verify the client's vaccination history to ensure they are due for the vaccine. Verifying the vaccination history helps prevent unnecessary vaccinations and ensures that the client receives the appropriate immunization at the right time. Choices A, B, and D are not directly related to the administration of the pneumococcal vaccine. Checking for allergies to eggs may be important for other vaccines, but it is not specifically relevant to pneumococcal vaccination. The client's current medications and blood pressure are important for general health assessment but are not directly related to verifying the need for a pneumococcal vaccine.

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