Nursing Elites

1. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?

• A. Ensure early ambulation
• B. Administer antibiotics as prescribed
• C. Maintain strict intake and output
• D. Monitor blood glucose levels

Correct answer: C

Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.

2. A client with a urinary tract infection is prescribed ciprofloxacin. What is the most important teaching the nurse should provide?

• A. Take the medication with milk to prevent stomach upset.
• B. Increase fluid intake to 2-3 liters per day.
• C. Avoid taking the medication with dairy products.
• D. Continue taking the medication even if symptoms improve.

Correct answer: B

Rationale: Ciprofloxacin can cause crystalluria, so increasing fluid intake to 2-3 liters per day helps flush out the medication and prevent crystal formation in the kidneys. This also ensures adequate hydration, which supports the body's ability to fight the infection. Choice A is incorrect because ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice D is incorrect because although it's important to complete the full course of antibiotics, it's equally crucial to report any improvement in symptoms to the healthcare provider.

3. Which foods should a healthcare provider recommend for a child with phenylketonuria (PKU) to avoid?

• A. Fresh fruit and vegetables
• B. Foods sweetened with aspartame
• C. Bread with honey
• D. Gluten-rich bread

Correct answer: B

Rationale: The correct answer is B: 'Foods sweetened with aspartame.' Children with PKU must avoid foods containing aspartame because it breaks down into phenylalanine, which can worsen their condition. Choice A, fresh fruit and vegetables, are generally healthy and safe for individuals with PKU. Choice C, bread with honey, is also safe unless the bread contains artificial sweeteners like aspartame. Choice D, gluten-rich bread, is not specifically problematic for individuals with PKU unless it contains aspartame or other substances high in phenylalanine.

4. The nurse administers an antibiotic for a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor?

• A. Platelet count and red blood cell count.
• B. White blood cell count and sputum culture.
• C. Hemoglobin A1c and glucose tolerance test.
• D. Arterial blood gases and serum electrolytes.

Correct answer: B

Rationale: The correct answer is B: White blood cell count and sputum culture. Monitoring white blood cell count and sputum cultures is essential to assess the effectiveness of the antibiotic in treating the respiratory tract infection. Changes in white blood cell count can indicate the body's response to infection, while sputum cultures help determine if the antibiotic is targeting the specific pathogens causing the infection. Choices A, C, and D are incorrect because platelet count, red blood cell count, hemoglobin A1c, glucose tolerance test, arterial blood gases, and serum electrolytes are not directly related to evaluating the effectiveness of an antibiotic in treating a respiratory tract infection.

5. A client with deep vein thrombosis (DVT) is prescribed warfarin. What lab value should the nurse review before administering the medication?

• A. Prothrombin time (PT)
• B. Hemoglobin and hematocrit (H&H)
• C. International Normalized Ratio (INR)
• D. Partial thromboplastin time (PTT)

Correct answer: C

Rationale: The correct answer is C: International Normalized Ratio (INR). Before administering warfarin to a client with deep vein thrombosis, the nurse should review the INR to ensure the client is within the therapeutic range. INR is specifically monitored for patients on warfarin therapy to assess the clotting ability of the blood. Choices A, B, and D are incorrect as they are not the primary lab value used to monitor warfarin therapy. Prothrombin time (PT) is used to measure how long blood takes to clot. Hemoglobin and hematocrit (H&H) assess for anemia and the blood's oxygen-carrying capacity. Partial thromboplastin time (PTT) is used to monitor heparin therapy, not warfarin.

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