Nursing Elites

1. 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.

2. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?

• A. Teach the client to report findings of IV extravasation
• B. Evaluate the patency of the IV
• C. Consult with the pharmacist about the prescription
• D. Verify the prescription with the provider

Correct answer: D

Rationale: The priority action is to verify the prescription with the provider. Verifying the prescription ensures patient safety by preventing fluid volume overload and dysrhythmias, which can result from infusing potassium too rapidly. Teaching the client about IV extravasation, evaluating IV patency, and consulting with the pharmacist are important but should come after verifying the prescription to ensure the ordered treatment is appropriate and safe for the client's condition.

3. A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?

• A. Contact provider if the cord turns black
• B. Clean the base of the cord with hydrogen peroxide daily
• C. Keep the cord dry until it falls off
• D. The cord stump will fall off in ten days

Correct answer: C

Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.

4. A healthcare provider is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the healthcare provider monitor?

• A. Serum glucose levels
• B. Serum potassium levels
• C. Blood pressure
• D. Both A and B

Correct answer: D

Rationale: When caring for a client receiving total parenteral nutrition (TPN), monitoring serum glucose levels is essential due to the impact TPN can have on glucose metabolism. Additionally, electrolytes like potassium should be monitored as they can be affected by TPN administration. Blood pressure monitoring is not directly related to TPN administration, making choices A and B the correct options to monitor in this scenario.

5. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?

• A. Constricted pupils
• B. Dilated pupils
• C. Increased reflexes
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.

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