Nursing Elites

1. A healthcare professional is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?

• A. PaO2 level of 89 mm Hg
• B. PaCO2 level of 55 mm Hg
• C. HCO3 level of 25 mEq/L
• D. pH level of 7.37

Correct answer: B

Rationale: The correct answer is B. A high PaCO2 level (55 mm Hg) in a client with chronic emphysema suggests respiratory acidosis, which requires further treatment. In chronic emphysema, impaired gas exchange leads to elevated carbon dioxide levels in the blood. Option A (PaO2 level of 89 mm Hg) is near the normal range and does not indicate immediate treatment. Option C (HCO3 level of 25 mEq/L) and option D (pH level of 7.37) are within normal limits and do not suggest the need for further treatment in this context.

2. What is the first intervention for a patient experiencing anaphylactic shock?

• A. Administer epinephrine
• B. Administer oxygen
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for anaphylactic shock as it helps reverse the severe allergic reaction by constricting blood vessels, increasing heart rate, and opening airways for improved breathing. Oxygen (Choice B) can be administered after epinephrine to support oxygenation. Corticosteroids (Choice C) may be used to prevent a biphasic reaction but are not the initial intervention. Antihistamines (Choice D) can help with itching and hives but do not address the life-threatening symptoms of anaphylaxis.

3. A nurse is caring for a client with heart failure receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate 60/min.
• B. Blood pressure 110/70 mm Hg.
• C. Serum potassium 4 mEq/L.
• D. Blood pressure 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.

4. A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime.
• B. You should expect your urine to turn orange while taking this medication.
• C. This medication can cause you to gain weight.
• D. Take this medication with food to reduce gastrointestinal discomfort.

Correct answer: D

Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.

5. A nurse is preparing to administer a controlled substance. Which of the following actions should the nurse take?

• A. Witness the waste of the controlled substance by another nurse
• B. Dispose of the controlled substance by yourself
• C. Leave the controlled substance in the client's room for later use
• D. Document the administration and sign off at the end of the shift

Correct answer: A

Rationale: The correct action for the nurse preparing to administer a controlled substance is to witness the waste of the controlled substance by another nurse. This practice is crucial to prevent misuse and ensure accurate documentation. Choice B is incorrect because disposing of the controlled substance by oneself without proper witnessing is not in accordance with safety protocols. Choice C is incorrect as leaving a controlled substance unattended in a client's room poses risks of diversion or unauthorized access. Choice D is incorrect because documenting the administration and signing off at the end of the shift is important but does not specifically address the issue of witnessing the waste of a controlled substance, which is a critical step in ensuring proper handling and accountability.

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