Nursing Elites

1. A healthcare professional is preparing to administer the initial dose of ceftriaxone to a client who has endometritis. Which of the following statements by the client should cause the healthcare professional to hold the medication and consult the provider?

• A. I have a severe allergy to amoxicillin
• B. I get sick when I take diuretics
• C. I have a history of hearing problems
• D. I take prednisone for my asthma

Correct answer: A

Rationale: A severe allergy to amoxicillin could indicate a potential cross-reactivity with ceftriaxone, so the medication should be held. Cross-reactivity between penicillins (like amoxicillin) and cephalosporins (like ceftriaxone) is a known concern due to their similar chemical structures. Choices B, C, and D do not directly contraindicate the administration of ceftriaxone for endometritis.

2. A patient is admitted with suspected pneumonia. What is the nurse's priority assessment?

• A. Auscultate the patient's lung sounds.
• B. Assess the patient's oxygen saturation.
• C. Monitor the patient's white blood cell count.
• D. Monitor the patient's skin integrity.

Correct answer: B

Rationale: The correct answer is to assess the patient's oxygen saturation. In suspected pneumonia, ensuring adequate oxygenation is critical to monitor respiratory function. Auscultating lung sounds is important but assessing oxygen saturation takes precedence as it directly reflects the patient's oxygen levels. Monitoring white blood cell count is more related to infection assessment rather than immediate respiratory status. Checking skin integrity is essential for overall patient care but is not the priority in a patient with suspected pneumonia.

3. What is the priority action for a patient with a fever?

• A. Administer an antipyretic medication as prescribed.
• B. Assess the patient's temperature regularly.
• C. Provide cooling measures such as a cool compress.
• D. Provide the patient with blankets for comfort.

Correct answer: B

Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.

4. A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

• A. Lock beds and wheelchairs when not in use
• B. Administer a sedative at bedtime
• C. Provide information about home safety checks
• D. Teach balance and strengthening exercises

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

5. A healthcare professional is planning care for a client who is scheduled for a lumbar puncture. Which of the following actions should the healthcare professional include?

• A. Restrict the client's fluid intake for 4 hours following the procedure
• B. Apply cold compresses to the puncture site after the procedure
• C. Instruct the client to increase oral fluid intake after the procedure
• D. Keep the client in a prone position for 12 hours after the procedure

Correct answer: C

Rationale: The correct action to include in caring for a client scheduled for a lumbar puncture is to instruct the client to increase oral fluid intake after the procedure. Increasing oral fluid intake helps replace cerebrospinal fluid lost during the lumbar puncture and reduces the risk of headaches. Restricting fluid intake (Choice A) is not recommended as it can lead to dehydration. Applying cold compresses (Choice B) is not necessary after a lumbar puncture. Keeping the client in a prone position for 12 hours (Choice D) is not required after a lumbar puncture and can cause discomfort and complications.

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