Nursing Elites

1. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?

• A. Administer the medication over 30 minutes.
• B. Monitor the client for a decrease in blood pressure during administration.
• C. Assess the IV site for infiltration during administration.
• D. Premedicate the client with an antiemetic prior to administration.

Correct answer: C

Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.

2. A nurse is caring for a client who has a prescription for spironolactone. Which of the following laboratory values should the nurse monitor?

• A. Sodium 140 mEq/L
• B. Calcium 9.5 mg/dL
• C. Potassium 5.2 mEq/L
• D. Magnesium 2.0 mEq/L

Correct answer: C

Rationale: The correct answer is C: Potassium 5.2 mEq/L. A potassium level of 5.2 mEq/L is elevated and should be monitored in clients taking spironolactone, which is a potassium-sparing medication. Monitoring potassium levels is crucial as spironolactone can cause hyperkalemia. Choices A, B, and D are incorrect because sodium, calcium, and magnesium levels are not typically affected by spironolactone. Therefore, the nurse should primarily focus on monitoring the potassium levels in this scenario.

3. A nurse is caring for a client who has a new diagnosis of hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Bradycardia.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: B

Rationale: The correct answer is B: Bradycardia. Bradycardia, or a slow heart rate, is a common finding in clients with hypothyroidism because of the decreased metabolic rate associated with this condition. Weight gain is also a common symptom of hypothyroidism due to the metabolic changes, making choice A incorrect. Tachycardia, or a rapid heart rate, is typically seen in hyperthyroidism, not hypothyroidism, so choice C is incorrect. Heat intolerance is more commonly associated with hyperthyroidism rather than hypothyroidism, making choice D incorrect.

4. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel. Which of the following statements should the nurse make?

• A. The nurse is legally responsible for the actions of the AP.
• B. An AP can perform tasks outside of their scope if they have been trained.
• C. An experienced AP can delegate tasks to another AP.
• D. An RN evaluates the client's needs to determine tasks to delegate.

Correct answer: D

Rationale: The correct statement is D: 'An RN evaluates the client's needs to determine which tasks are appropriate to delegate to assistive personnel.' This is an essential step in the delegation process to ensure that tasks are assigned appropriately based on the client's condition and the competencies of the assistive personnel. Option A is incorrect because while the nurse retains accountability for delegation decisions, the AP is responsible for their actions. Option B is incorrect as tasks should be within the AP's scope of practice regardless of training. Option C is incorrect as delegation typically involves assigning tasks from the RN to the AP, not between APs.

5. A client with heart failure has a new prescription for furosemide. Which of the following instructions should the nurse include?

• A. You should weigh yourself once a week while taking this medication.
• B. You should eat foods rich in potassium while taking this medication.
• C. You should take this medication at bedtime.
• D. You should take this medication with food to avoid stomach upset.

Correct answer: B

Rationale: The correct answer is B. Clients taking furosemide, a potassium-wasting diuretic, should increase their intake of potassium-rich foods to prevent hypokalemia. Option A is incorrect because weight monitoring is crucial for furosemide due to fluid loss. Option C is incorrect as furosemide is usually taken in the morning to prevent nighttime diuresis. Option D is incorrect because furosemide is best taken on an empty stomach for better absorption.

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