Nursing Elites

1. How should a healthcare provider assess a patient with sepsis?

• A. Monitor vital signs and administer fluids
• B. Monitor for fever and administer antibiotics
• C. Check for tachycardia and elevated white blood cell count
• D. Administer fluids and provide nutritional support

Correct answer: A

Rationale: In sepsis, it is crucial to monitor vital signs to assess the patient's condition and administer fluids to maintain circulation. This approach helps in stabilizing blood pressure and perfusion. While monitoring for fever and administering antibiotics (choice B) is important in managing sepsis, the initial priority lies in assessing and stabilizing the patient's hemodynamic status. Checking for tachycardia and elevated white blood cell count (choice C) can be part of the assessment but does not encompass the immediate intervention needed in sepsis. Administering fluids and providing nutritional support (choice D) are essential in managing sepsis, but the primary step should be to assess the patient's condition through vital sign monitoring.

2. A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?

• A. Instruct the client to perform ankle pumps
• B. Administer anticoagulant therapy as prescribed
• C. Maintain the client in a prone position
• D. Encourage the client to ambulate as tolerated

Correct answer: B

Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.

3. A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?

• A. Frequency
• B. Dosage
• C. Timing of doses
• D. Route

Correct answer: B

Rationale: The nurse should question the dosage of haloperidol as it is typically administered in milligrams (mg) and not milliliters (mL). The dosage should be expressed in a standardized unit for accuracy and to prevent medication errors. Frequency, timing of doses, and route are also important components of a prescription, but in this case, the nurse should focus on the unusual dosage form.

4. Which of the following findings indicates a need for immediate attention in a client diagnosed with delirium?

• A. Confusion and disorientation that resolve with rest
• B. A blood pressure reading of 110/70
• C. Irritability and agitation that worsen throughout the day
• D. Mild confusion during the evening hours

Correct answer: C

Rationale: The correct answer is C: Irritability and agitation that worsen throughout the day. These symptoms are concerning in a client diagnosed with delirium as they may indicate an exacerbation of the condition or an underlying cause that requires immediate attention. Option A describes symptoms that resolve with rest, which may not be as urgent. Option B provides a normal blood pressure reading, which is not typically associated with immediate attention in delirium cases. Option D describes mild confusion during specific hours, which may not be as critical as worsening symptoms throughout the day.

5. A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?

• A. In the afternoon
• B. As soon as the client awakens in the morning
• C. Before bedtime
• D. Immediately after lunch

Correct answer: B

Rationale: The correct answer is B: 'As soon as the client awakens in the morning.' Sputum specimens should be collected early in the morning to obtain a concentrated sample. This timing ensures that the specimen is less diluted, providing a more accurate analysis. Choices A, C, and D are incorrect as they do not align with the optimal timing for collecting a sputum specimen, which is in the morning.

Similar Questions