Nursing Elites

1. A client with tuberculosis is about to start combination drug therapy. Which of the following medications should the nurse plan to administer? (SATA)

• A. Acyclovir
• B. Pyrazinamide
• C. Isoniazid
• D. Rifampin

Correct answer: B

Rationale: The correct answer is B: Pyrazinamide. In the treatment of tuberculosis, a combination drug therapy is usually employed. Pyrazinamide and rifampin are two key drugs used in this regimen. Acyclovir is an antiviral medication used for herpes infections, not for tuberculosis. Isoniazid is another medication used in tuberculosis treatment, but in this case, the question asked for medications to administer, and the correct choices should be those commonly used in tuberculosis combination therapy.

2. Which action by the nurse will help prevent ventilator-associated pneumonia (VAP) in a patient on mechanical ventilation?

• A. Provide oral care every 4 hours.
• B. Reposition the patient every 2 hours.
• C. Suction the patient as needed.
• D. Administer antibiotics as prescribed.

Correct answer: A

Rationale: The correct answer is A. Providing oral care every 4 hours helps prevent ventilator-associated pneumonia by reducing the buildup of bacteria in the mouth that can be aspirated into the lungs. Repositioning the patient every 2 hours is important for preventing pressure ulcers but is not directly related to preventing VAP. Suctioning the patient as needed is essential for maintaining airway patency but does not specifically prevent VAP. Administering antibiotics as prescribed is a treatment for infections but does not prevent VAP.

3. A healthcare professional is assessing a client who has a hip fracture. Which of the following findings should the healthcare professional expect?

• A. Hip pallor
• B. Leg abduction
• C. Muscle spasms
• D. Leg lengthening

Correct answer: C

Rationale: Muscle spasms are a common finding in clients with hip fractures. The muscle spasms occur due to the body's natural response to the injury, causing involuntary contractions. Hip pallor (Choice A) is not typically associated with hip fractures. Leg abduction (Choice B) and leg lengthening (Choice D) are not typical findings in clients with hip fractures, as the fracture usually results in limited range of motion and shortening of the affected limb.

4. A healthcare provider is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

• A. Bladder scan shows 525 mL
• B. Absent urinary output for 1 hour
• C. Cloudy urine
• D. Bloody urine

Correct answer: A

Rationale: The correct answer is A. A large bladder scan result (525 mL) suggests catheter blockage and may require irrigation to resolve. Choice B (absent urinary output for 1 hour) could indicate a different issue such as urinary retention but does not specifically indicate the need for catheter irrigation. Choices C (cloudy urine) and D (bloody urine) may suggest infection or other urinary issues, but they do not directly indicate the need for catheter irrigation.

5. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?

• A. Administer acetaminophen
• B. Stop the transfusion
• C. Slow the transfusion rate
• D. Administer antihistamines

Correct answer: B

Rationale: The correct answer is to stop the transfusion (Choice B). The symptoms described - chills, headache, and low back pain - are indicative of a transfusion reaction. The priority action is to immediately stop the transfusion to prevent further complications such as more severe reactions like hemolytic reactions or anaphylaxis. Administering acetaminophen (Choice A) may help with symptoms but does not address the underlying cause. Slowing the transfusion rate (Choice C) may not be sufficient if a serious transfusion reaction is occurring. Administering antihistamines (Choice D) is not the priority in this situation; stopping the transfusion takes precedence to ensure patient safety.

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