Nursing Elites

1. A school nurse is providing care for students in an elementary education facility. What intervention by the nurse addresses the primary level of prevention?

• A. Monitor for signs of illness.
• B. Teach students about healthy food choices.
• C. Administer medication to students with chronic conditions.
• D. Monitor immunization compliance.

Correct answer: B

Rationale: The correct answer is B: Teach students about healthy food choices. Teaching healthy habits like proper nutrition is an example of primary prevention because it aims to prevent disease before it occurs. Choice A, monitoring for signs of illness, is more related to secondary prevention (early detection and treatment). Choice C, administering medication to students with chronic conditions, is a form of tertiary prevention (managing existing conditions to prevent complications). Choice D, monitoring immunization compliance, is also a form of primary prevention but focuses on preventing specific infectious diseases through immunization rather than general health promotion.

2. A nurse is preparing to administer a dose of ampicillin. Which of the following actions should the nurse take?

• A. Administer it with food
• B. Check for penicillin allergy
• C. Monitor liver function
• D. Administer it intramuscularly

Correct answer: B

Rationale: The correct answer is to 'Check for penicillin allergy.' Before administering ampicillin, it is crucial to assess the patient for any history of penicillin allergy. This is essential to prevent an adverse allergic reaction, as ampicillin belongs to the penicillin class of antibiotics. Administering ampicillin with food (Choice A) is not a standard requirement and does not impact its effectiveness. Monitoring liver function (Choice C) is not directly related to the immediate pre-administration assessment for ampicillin. Administering ampicillin intramuscularly (Choice D) is not typically the route of administration for this antibiotic, as it is usually given intravenously or orally.

3. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.

4. A patient scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' Which response should the nurse make?

• A. Tell the patient they need the surgery
• B. Encourage the patient to express their thoughts
• C. Ignore the comment and proceed
• D. Insist the patient needs to proceed with the surgery

Correct answer: B

Rationale: Encouraging the patient to express their thoughts is the best response in this situation. It allows the patient to voice their concerns or reasons for canceling the surgery, which can help the healthcare team address any misunderstandings or fears the patient may have. Choices A and D are too directive and do not consider the patient's autonomy and right to make informed decisions about their care. Choice C is inappropriate as it disregards the patient's expressed decision and fails to address the underlying issue.

5. A nurse is caring for a client who has congestive heart failure. Which of the following prescriptions from the provider should the nurse anticipate?

• A. Call the provider if the client’s respiratory rate is less than 18/min
• B. Administer 500 mL IV bolus of 0.9% sodium chloride over 1 hour
• C. Administer enalapril 2.5 mg PO twice daily
• D. Call the provider if the client’s pulse rate is less than 80/min

Correct answer: C

Rationale: The correct answer is C. Enalapril is an ACE inhibitor commonly prescribed for clients with congestive heart failure to help reduce blood pressure and fluid overload. Option A is incorrect as in congestive heart failure, a lower respiratory rate could be a sign of worsening condition and needs immediate attention rather than waiting to call the provider. Option B is incorrect as administering a large IV bolus of sodium chloride could exacerbate fluid overload in a client with heart failure. Option D is incorrect as a pulse rate lower than 80/min may not necessarily indicate a problem in a client with congestive heart failure.

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