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 with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?

• A. I will make sure my medications are enteric-coated.
• B. My stoma will drain liquid continuously.
• C. I will change my pouch system every two weeks.
• D. My stoma size will stay the same after it heals.

Correct answer: B

Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.

3. A nurse is caring for a client with end-stage osteoporosis who is experiencing severe pain and a respiratory rate of 14/min. Which medication should the nurse prioritize?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: In this situation, the nurse should prioritize administering Hydromorphone (choice B), an opioid analgesic, to manage the severe pain effectively. Opioids are the first-line treatment for severe pain, especially in end-stage conditions like osteoporosis. Promethazine (choice A) is an antihistamine and antiemetic, not a potent analgesic. Ketorolac (choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may not provide sufficient pain relief in severe cases. Amitriptyline (choice D) is a tricyclic antidepressant used for neuropathic pain and depression, but it is not the first choice for managing severe pain in this scenario.

4. A healthcare professional is assessing a client for signs of hyperglycemia. Which of the following findings should the healthcare professional look for?

• A. Increased thirst
• B. Weight gain
• C. Decreased urination
• D. Fatigue

Correct answer: A

Rationale: Increased thirst is a classic symptom of hyperglycemia due to the body trying to eliminate excess glucose through urine, leading to dehydration and increased thirst. Weight gain, decreased urination, and fatigue are not typical signs of hyperglycemia. Weight gain is more commonly associated with conditions like hypothyroidism or fluid retention. Decreased urination is not a typical symptom of hyperglycemia, as high blood sugar levels usually lead to increased urination. Fatigue can be a symptom of hyperglycemia, but it is not as specific or characteristic as increased thirst.

5. A newborn demonstrates respiratory distress, and routine suctioning with the bulb syringe is unsuccessful. What is the next nursing intervention?

• A. Initiate chest compressions
• B. Administer oxygen
• C. Suction with a mechanical device
• D. Notify the healthcare provider

Correct answer: C

Rationale: When routine suctioning with a bulb syringe is unsuccessful in a newborn demonstrating respiratory distress, the next appropriate nursing intervention is to suction with a mechanical device. This method ensures effective removal of any airway obstruction. Initiating chest compressions (Choice A) is not indicated in this scenario as the primary concern is airway clearance. Administering oxygen (Choice B) may be necessary, but addressing the airway obstruction should take precedence. Notifying the healthcare provider (Choice D) can be considered after attempting mechanical suction if the newborn's condition does not improve.

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