Nursing Elites

1. A nurse is preparing to administer vancomycin IV to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

• A. Administer the medication over 60 minutes
• B. Monitor the client's blood glucose level during administration
• C. Infuse the medication rapidly to reduce the risk of infection
• D. Administer the medication using a filter needle

Correct answer: A

Rationale: The correct action the nurse should take is to administer the medication over 60 minutes. This is important because administering vancomycin over 60 minutes helps prevent red man syndrome, a reaction that can occur with rapid infusion. Monitoring the client's blood glucose level (Choice B) is unrelated to vancomycin administration. Infusing the medication rapidly (Choice C) is incorrect and can lead to adverse reactions. Administering the medication using a filter needle (Choice D) is unnecessary for vancomycin administration.

2. A client with a new diagnosis of hypertension is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my potassium intake while taking this medication.
• B. I will need to take medication for the rest of my life.
• C. I will avoid using salt substitutes.
• D. I will avoid drinking grapefruit juice.

Correct answer: C

Rationale: The correct answer is C. Clients with hypertension should avoid salt substitutes because they often contain potassium, which can raise potassium levels. Choice A is incorrect as decreasing potassium intake is not necessary unless advised by a healthcare provider. Choice B is incorrect as not all clients with hypertension need to take medication for life. Choice D is incorrect as grapefruit juice does not significantly impact hypertension management.

3. What is the most appropriate nursing intervention for a patient experiencing hypoglycemia?

• A. Administer IV glucose
• B. Administer oral glucose
• C. Check blood sugar in 15 minutes
• D. Provide a high-calorie snack

Correct answer: B

Rationale: The most appropriate nursing intervention for a patient experiencing hypoglycemia is to administer oral glucose. Oral glucose is usually sufficient for treating mild hypoglycemia and can be administered quickly and easily. Administering IV glucose (Choice A) is reserved for severe cases where the patient is unable to swallow or unconscious. Checking blood sugar in 15 minutes (Choice C) is important but providing glucose should come first. Providing a high-calorie snack (Choice D) may not be as rapidly effective as administering oral glucose in quickly raising blood sugar levels in a patient experiencing hypoglycemia.

4. When digitally evacuating stool from a client with a fecal impaction, what action should the nurse take?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with the removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating stool from a client with a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and is the appropriate method for addressing fecal impaction. Choice B is incorrect as stimulating peristalsis will not directly assist in evacuating the impacted stool. Choice C is incorrect as applying pressure to the abdomen is not the recommended method for stool evacuation. Choice D is incorrect as increasing fluid intake does not directly aid in digitally evacuating the stool.

5. A client with heart failure is being educated by a nurse about fluid restrictions. Which of the following instructions should the nurse include?

• A. Limit your fluid intake to 3 liters per day.
• B. Increase your fluid intake to 5 liters per day.
• C. Avoid drinking more than 1 liter of fluid per day.
• D. You can drink as much fluid as you want during meals.

Correct answer: C

Rationale: The correct answer is C: "Avoid drinking more than 1 liter of fluid per day." Clients with heart failure are typically advised to limit their fluid intake to around 1 liter per day to prevent fluid overload, which can worsen their condition. Choices A, B, and D are incorrect because they suggest fluid intakes that are higher than the recommended limit, which could lead to fluid retention and exacerbate heart failure symptoms.

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