Nursing Elites

1. During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement first?

• A. Initiate isolation precautions
• B. Administer an antipyretic
• C. Draw blood cultures
• D. Prepare for lumbar puncture

Correct answer: A

Rationale: The correct answer is to initiate isolation precautions. This is the priority action because the patient presents with symptoms that could be indicative of meningitis, an infectious disease that requires isolation to prevent its spread. Administering an antipyretic (Choice B) may help manage the fever but does not address the need for isolation. Drawing blood cultures (Choice C) and preparing for a lumbar puncture (Choice D) are important steps in diagnosing meningitis but should come after initiating isolation precautions to prevent potential transmission of the infection to others.

2. A client with diabetes mellitus is scheduled to have blood drawn for a fasting blood glucose determination in the morning. What does the nurse tell the client is acceptable to consume on the morning of the test?

• A. Water
• B. Tea without sugar
• C. Coffee without milk
• D. Clear liquids like apple juice

Correct answer: A

Rationale: The correct answer is A: Water. A client scheduled for a fasting blood glucose test should only consume water after midnight to ensure accurate test results. Choosing options B, C, or D, which include tea, coffee, or clear liquids like apple juice, is incorrect as they may contain substances that can affect the blood glucose levels, leading to inaccurate test results.

3. A client recovering from surgery has a large abdominal wound. Which of the following foods, high in vitamin C, should the nurse encourage the client to eat to promote wound healing?

• A. Steak
• B. Veal
• C. Cheese
• D. Oranges

Correct answer: D

Rationale: Oranges are a rich source of vitamin C, which is essential for wound healing due to its role in collagen synthesis. Citrus fruits like oranges, as well as other fruits and vegetables such as strawberries, kiwi, bell peppers, and broccoli, are high in vitamin C. Meats like steak and veal are not significant sources of vitamin C; they are primarily sources of protein. Cheese is not a good source of vitamin C but does provide calcium and protein.

4. Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay the development of:

• A. Chronic obstructive pulmonary disease (COPD).
• B. Pancreatic cancer.
• C. Renal failure.
• D. Cerebrovascular accident.

Correct answer: C

Rationale: The correct answer is C: Renal failure. ACE inhibitors are commonly used in clients with diabetes mellitus to help reduce the progression of diabetic nephropathy by improving renal blood flow. This medication class can help prevent or delay the development of renal failure in these clients. Choices A, B, and D are incorrect because ACE inhibitors do not have a direct impact on preventing or delaying the development of chronic obstructive pulmonary disease, pancreatic cancer, or cerebrovascular accidents in clients with diabetes mellitus.

5. A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:

• A. 85%
• B. 89%
• C. 95%
• D. 100%

Correct answer: C

Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the expected oxygen saturation level is at least 95%. Oxygen saturation levels below 95% may indicate hypoxemia, which can compromise tissue perfusion and oxygen delivery to vital organs. Therefore, maintaining oxygen saturation above 95% is crucial to ensure adequate oxygenation post-surgery. Choices A, B, and D are incorrect as they represent oxygen saturation levels that are below the expected value for a client without a history of respiratory disease, which should be at least 95%.

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