Nursing Elites

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

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Mood changes

Correct answer: A

Rationale: When administering sertraline, assessing blood pressure is crucial as this medication can potentially affect blood pressure levels. Monitoring blood pressure before giving sertraline helps ensure patient safety and allows for appropriate interventions if any significant changes are noted. Heart rate, respiratory rate, and mood changes are important assessments but are not typically the first priority when administering sertraline. While heart rate and respiratory rate can also be affected by sertraline, blood pressure assessment is a higher priority due to the medication's known effects on blood pressure regulation.

2. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

3. A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?

• A. Eye contact
• B. Personal space
• C. Touch
• D. All of the above

Correct answer: D

Rationale: In a cultural assessment, it is essential to consider various cultural variables that can impact communication and interactions. Eye contact, personal space, and touch are examples of cultural variables that can vary among different cultural groups. These variables influence how individuals perceive and engage in communication. Understanding and respecting these differences are crucial for effective and culturally sensitive care. Therefore, the correct answer is 'All of the above.' Choices A, B, and C are incorrect because each of them represents a cultural variable that should be considered during a cultural assessment.

4. A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?

• A. A client who has an ileal conduit and mucus in the pouch
• B. Client with arteriovenous fistula with additional vibration palpated
• C. A client with chronic kidney disease and cloudy dialysate outflow
• D. A client with transurethral resection of the prostate with red-tinged urine

Correct answer: C

Rationale: The nurse should assess the client with chronic kidney disease and cloudy dialysate outflow first because cloudy dialysate outflow suggests peritonitis, a serious complication of peritoneal dialysis that requires immediate intervention. Assessing and addressing peritonitis promptly is crucial to prevent further complications and ensure the client's safety. Choices A, B, and D present important findings that require attention but are not as urgent as peritonitis, which can quickly escalate and endanger the client's health.

5. A nurse is preparing to administer prochlorperazine 2.5 mg IV. Available is prochlorperazine injection 5 mg/mL. How many mL should the nurse administer?

• A. 0.2 mL
• B. 0.5 mL
• C. 1.0 mL
• D. 1.5 mL

Correct answer: B

Rationale: To determine the volume of prochlorperazine to administer, divide the prescribed dose (2.5 mg) by the concentration of the medication (5 mg/mL). This calculation results in 0.5 mL. Therefore, the nurse should administer 0.5 mL to deliver the correct dose. Choice A (0.2 mL) is incorrect as it miscalculates the dosage. Choices C (1.0 mL) and D (1.5 mL) are also incorrect as they do not accurately reflect the calculated volume needed for the dose.

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