Nursing Elites

1. A nurse is preparing to administer a dose of vancomycin IV to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse take?

• A. Administer the medication over 15 minutes.
• B. Monitor the client's urine output every 8 hours.
• C. Check the client's creatinine level before administering the medication.
• D. Assess the client for a history of allergies to antibiotics.

Correct answer: C

Rationale: The correct action for the nurse to take is to check the client's creatinine level before administering vancomycin. Vancomycin is known to be nephrotoxic, so assessing the client's renal function before administering the medication is crucial to prevent further kidney damage. Administering the medication over 15 minutes (Choice A) is not the priority in this scenario as renal function assessment takes precedence. Monitoring urine output (Choice B) is important for assessing renal function but checking creatinine level directly provides more accurate information. Assessing for allergies to antibiotics (Choice D) is also important but not as essential as checking the creatinine level due to the nephrotoxic nature of vancomycin.

2. A nurse is caring for a client who is 2 hours postoperative following a cholecystectomy. Which of the following actions should the nurse take to prevent postoperative complications?

• A. Instruct the client to perform deep breathing and coughing exercises.
• B. Have the client wear sequential compression devices (SCDs).
• C. Place the client in a supine position with the head of the bed flat.
• D. Encourage the client to ambulate every 2 hours.

Correct answer: B

Rationale: The correct answer is B: Have the client wear sequential compression devices (SCDs). Following a cholecystectomy, the client is at risk for venous thromboembolism (VTE) due to reduced mobility and surgical stress. SCDs help prevent VTE by promoting venous return and reducing the risk of blood clots. Choices A, C, and D are incorrect. While deep breathing and coughing exercises are essential postoperatively, SCDs take precedence in preventing VTE. Placing the client in a supine position with the head of the bed flat can increase the risk of respiratory complications. Encouraging ambulation is important, but SCDs are a higher priority in this situation to prevent VTE.

3. A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid using aspirin for pain.
• B. I will consume dairy products to increase my calcium intake.
• C. I will drink 1.5 to 2 liters of fluid each day.
• D. I will need to limit my intake of fiber.

Correct answer: A

Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.

4. What is the best method to assess pain in a non-verbal patient?

• A. Observe for facial expressions
• B. Observe for restlessness
• C. Observe for sweating
• D. Check for non-verbal cues

Correct answer: A

Rationale: The correct answer is to observe for facial expressions when assessing pain in a non-verbal patient. Facial expressions can provide vital clues about the patient's pain level and discomfort. Choices B and C, observing for restlessness and sweating, can be less specific and may indicate other issues besides pain. Choice D, checking for non-verbal cues, is too broad and does not specify the crucial aspect of focusing on facial expressions.

5. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

• A. Administer the immunization in the deltoid muscle
• B. Apply a cold compress to the injection site
• C. Apply pressure to the injection site for 5 minutes
• D. Administer a local anesthetic at the injection site

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

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