Nursing Elites

1. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Watery diarrhea
• B. Nausea
• C. Headache
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention. Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.

2. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

• A. Expresses an understanding of the procedure.
• B. NPO for 6 hrs.
• C. No known drug allergies.
• D. Intravenous access intact.

Correct answer: A

Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.

3. A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6-gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

• A. Urine output of 20 ml/hour
• B. Blood pressure of 138/88
• C. Respiratory rate of 18 breaths/min
• D. Temperature of 99.8°F

Correct answer: A

Rationale: A urine output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium sulfate. This decreased urine output can lead to magnesium toxicity and impaired kidney function. Blood pressure of 138/88 is within normal limits for pregnancy and does not indicate an immediate concern related to magnesium sulfate. A respiratory rate of 18 breaths/min is normal, and a temperature of 99.8°F is slightly elevated but not a priority in the context of severe preeclampsia and magnesium sulfate administration.

4. A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer intravenous fluids as prescribed.
• B. Administer insulin as prescribed.
• C. Monitor the client's urine output.
• D. Check the client's blood glucose level.

Correct answer: B

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. Insulin helps to reduce blood glucose levels and correct metabolic acidosis, which are critical in the treatment of DKA. While administering intravenous fluids is essential to manage dehydration, insulin takes precedence in treating the underlying cause of DKA. Monitoring urine output is important for assessing renal function but is not the primary intervention in managing DKA. Checking the client's blood glucose level is necessary, but administering insulin to reduce high blood glucose levels is the key priority in treating DKA.

5. A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?

• A. I should check my feet every day for cuts or blisters.
• B. I need to moisturize my feet daily, especially between my toes.
• C. I should wear comfortable shoes that fit well.
• D. I should avoid walking barefoot, even indoors.

Correct answer: B

Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.

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