Nursing Elites

1. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

• A. Measure the client's oxygen saturation before taking further action
• B. Administer a PRN dose of nitroglycerin (Nitrostat)
• C. Administer the dose of furosemide as scheduled
• D. Hold the dose of furosemide until contacting the healthcare provider

Correct answer: C

Rationale: Administering the scheduled dose of furosemide is appropriate when a client with heart failure has an elevated BNP level. BNP elevation indicates fluid overload, and furosemide is a diuretic that helps in reducing excess fluid. Measuring the client's oxygen saturation (Choice A) is not directly related to addressing fluid overload. Administering nitroglycerin (Choice B) is not indicated for managing elevated BNP levels. Holding the furosemide dose (Choice D) would delay appropriate treatment for fluid overload.

2. The nurse is caring for a client who is 2 days post-op following an abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps prevent infection and keeps the wound moist, which is crucial in promoting healing and preventing further complications. Option B, notifying the healthcare provider, is important but should come after addressing the wound. Administering pain medication (Option C) may be necessary but is not the first action to take in this emergency situation. Covering the wound with an abdominal binder (Option D) is not appropriate and may cause further harm by applying pressure to the protruding bowel.

3. What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

• A. Bladder palpation
• B. Inspection of the mouth
• C. Blood glucose monitoring
• D. Auscultation of breath sounds

Correct answer: B

Rationale: The correct answer is B: Inspection of the mouth. This assessment technique is crucial for monitoring gingival hyperplasia, a common side effect of phenytoin. Bladder palpation (choice A) is not relevant to monitoring for phenytoin's side effects. Blood glucose monitoring (choice C) is important for clients with diabetes but is not specifically related to phenytoin. Auscultation of breath sounds (choice D) is more relevant for assessing respiratory conditions, not side effects of phenytoin.

4. A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take?

• A. Tell the client to go directly to the hospital for admission to labor and delivery for active labor
• B. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour
• C. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection
• D. Advise the client to rest and hydrate, then return if contractions become more regular

Correct answer: B

Rationale: The client should be instructed to call when contractions are 5 minutes apart for an hour to ensure she is in active labor before going to the hospital.

5. A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?

• A. Maintain a quiet environment
• B. Ensure the linens are clean and dry
• C. Place an air deodorizer in the room
• D. Measure all emesis accurately

Correct answer: D

Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.

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