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 client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

• A. “Lie on your left side.”
• B. “Lie on your right side.”
• C. “Increase your fluid intake.”
• D. “Decrease your fluid intake.”

Correct answer: B

Rationale: Following a liver biopsy, the nurse should instruct the client to lie on the right side to promote hemostasis. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Instructing the client to lie on the left side (Choice A) would not provide the same benefit. Increasing fluid intake (Choice C) is generally beneficial post-procedure to prevent dehydration and promote healing. Decreasing fluid intake (Choice D) is not advisable as it can lead to dehydration and potential complications.

3. A nurse is teaching about measures to promote sleep with insomnia. What statement indicates understanding?

• A. Take naps throughout the day
• B. Reduce fluid intake 2 hours before bedtime
• C. Drink coffee to help stay awake
• D. Increase screen time before bed

Correct answer: B

Rationale: The correct answer is B. Reducing fluid intake before bedtime helps prevent interruptions in sleep due to bathroom visits, which is crucial for individuals with insomnia. Taking naps throughout the day (choice A) may disrupt nighttime sleep. Drinking coffee (choice C) is counterproductive as it contains caffeine, which can interfere with falling asleep. Increasing screen time before bed (choice D) can negatively impact sleep quality due to the stimulating effects of screens.

4. 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.

5. A nurse is providing teaching about breastfeeding to a client who is postpartum. Which of the following instructions should the nurse include?

• A. Wash your nipples with soap after each feeding.
• B. Place your baby to your breast for 5 minutes every 4 hours.
• C. Ensure your newborn has at least six wet diapers per day.
• D. Give your newborn 30 mL of water between feedings.

Correct answer: C

Rationale: The correct answer is C: 'Ensure your newborn has at least six wet diapers per day.' Six or more wet diapers per day is an indicator that the newborn is receiving adequate breast milk, making this an important part of breastfeeding education. Choice A is incorrect because washing nipples with soap after each feeding can lead to dryness and cracking. Choice B is incorrect as babies should nurse on demand rather than on a strict schedule of 5 minutes every 4 hours. Choice D is incorrect as giving water to a newborn between feedings is not recommended and can interfere with breastfeeding.

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