Nursing Elites

1. A patient with tuberculosis is started on rifampin. What advice should the nurse provide?

• A. Limit intake of green leafy vegetables.
• B. Expect orange-red discoloration of body fluids.
• C. Avoid exposure to sunlight.
• D. Take the medication with antacids.

Correct answer: B

Rationale: The correct advice for a patient starting rifampin is to expect orange-red discoloration of body fluids. Rifampin can cause harmless orange-red discoloration of body fluids, which may include urine, sweat, saliva, and tears. It is important for the patient to be aware of this side effect as it can stain clothing and contact lenses. Limiting the intake of green leafy vegetables is not necessary with rifampin. Avoiding exposure to sunlight is more commonly associated with other medications like tetracyclines, not rifampin. Taking rifampin with antacids is not recommended as antacids can reduce the absorption of rifampin, decreasing its effectiveness in treating tuberculosis.

2. The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?

• A. Drowsiness.
• B. Itching.
• C. Nausea.
• D. Respiratory rate of 8 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 8 breaths per minute indicates severe respiratory depression, a life-threatening side effect of opioid therapy. Immediate intervention is crucial to prevent respiratory failure. Monitoring and managing respiratory status are critical in clients receiving opioids to prevent adverse events. Drowsiness, itching, and nausea are common side effects of morphine but are not as immediately life-threatening as severe respiratory depression.

3. The healthcare provider is preparing to administer a blood transfusion. Which action is most important to ensure client safety?

• A. Check the client's vital signs before starting the transfusion.
• B. Verify the client's identity and blood compatibility.
• C. Administer the blood with normal saline.
• D. Monitor the client for the first 15 minutes of the transfusion.

Correct answer: B

Rationale: Verifying the client's identity and blood compatibility is the most critical step in ensuring client safety during a blood transfusion. This process helps prevent transfusion reactions by confirming that the correct blood product is being administered to the right patient.

4. When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?

• A. Are you allergic to any other medications?
• B. How often have you taken penicillin in the past?
• C. Is anyone else in your family allergic to penicillin?
• D. What happens to you when you take penicillin?

Correct answer: D

Rationale: Questioning the client about the specific allergic reaction to penicillin is crucial for assessing the severity and type of allergic response, aiding in determining appropriate treatment and avoiding potential adverse reactions.

5. When covering another nurse's assignment during a lunch break, based on the status report provided, which client should the charge nurse check first?

• A. The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl.
• B. The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
• C. The client post-triple coronary bypass four days ago who has serosanguinous drainage in the chest tube.
• D. The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.

Correct answer: D

Rationale: The client with a pneumothorax and a pulse oximeter reading of 90% indicates potential respiratory compromise, requiring immediate attention to prevent further deterioration.

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