Nursing Elites

1. The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?

• A. Heart rate of 88 beats per minute
• B. Blood pressure of 100/60
• C. Oxygen saturation of 94%
• D. Respiratory rate of 16

Correct answer: C

Rationale: The correct answer is C. Oxygen saturation levels below 95% indicate hypoxia and require immediate intervention. A heart rate of 88 beats per minute, a blood pressure of 100/60, and a respiratory rate of 16 are within normal ranges and do not require immediate intervention. Oxygen saturation is a critical parameter reflecting the client's oxygenation status.

2. An adolescent client with meningococcal meningitis is receiving a continuous IV infusion of penicillin G. How many mL/hour should the nurse program the infusion pump to deliver?

• A. 83
• B. 85
• C. 87
• D. 90

Correct answer: A

Rationale: The correct answer is A: 83. The pharmacy provided the infusion at 10 million units per liter, which requires a rate of 83 mL/hour. To calculate this, multiply the dosage by the volume of the IV solution and divide by the concentration of the IV solution in million units: 10 million units per liter x 8.3 L = 83 mL/hour. Choices B, C, and D are incorrect as they do not align with the calculation based on the given information.

3. The nurse is developing a teaching plan for a client receiving chemotherapy. Which of the following should be the nurse's first priority?

• A. The client will maintain adequate nutrition.
• B. The client will manage side effects of treatment.
• C. The client will recognize signs and symptoms of infection.
• D. The client will experience a reduction in pain.

Correct answer: C

Rationale: The correct answer is C. Recognizing signs and symptoms of infection should be the nurse's first priority when developing a teaching plan for a client receiving chemotherapy. Chemotherapy often compromises the immune system, making patients more susceptible to infections. Early identification and prompt treatment of infections are crucial to prevent complications. Options A, B, and D are important aspects of care but recognizing signs of infection takes precedence due to the potential life-threatening consequences in clients undergoing chemotherapy treatment.

4. A client with a history of stroke is receiving warfarin. What is the nurse's priority assessment?

• A. Check the client's blood pressure.
• B. Assess for signs of bleeding.
• C. Assess the client's neurological status.
• D. Monitor the client's intake and output.

Correct answer: B

Rationale: The correct answer is to assess for signs of bleeding. Warfarin is an anticoagulant that increases the risk of bleeding in patients. Monitoring for signs of bleeding such as easy bruising, petechiae, blood in urine or stool, or unusual bleeding from gums is crucial. Checking the client's blood pressure (choice A) is important but not the priority in this situation. Assessing the client's neurological status (choice C) is essential in stroke patients but is not the priority related to warfarin therapy. Monitoring intake and output (choice D) is important for overall assessment but is not the priority when a client is on warfarin, as assessing for bleeding takes precedence.

5. Which dietary instruction is most important for a client with renal disease?

• A. Avoid all protein-rich foods.
• B. Limit fluid intake to 1500 ml/day.
• C. Increase potassium intake to prevent weakness.
• D. Eat small, frequent meals high in carbohydrates.

Correct answer: B

Rationale: The most important dietary instruction for a client with renal disease is to limit fluid intake to 1500 ml/day. This is essential to prevent fluid overload, manage electrolyte balance, and reduce strain on the kidneys. Choice A is incorrect because while protein restriction may be necessary in some cases, avoiding all protein-rich foods is not recommended as some protein intake is essential for overall health. Choice C is incorrect because increasing potassium intake is generally not advised for clients with renal disease, as they often need to limit potassium intake. Choice D is also incorrect because while consuming small, frequent meals may be helpful, emphasizing a diet high in carbohydrates is not typically the primary focus for clients with renal disease.

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