Nursing Elites

1. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse?

• A. Serum creatinine of 4.5 mg/dL (398 μmol/L SI)
• B. Temperature of 101.3°F
• C. Blood pressure of 140/90 mmHg
• D. Heart rate of 88 bpm

Correct answer: A

Rationale: A serum creatinine level of 4.5 mg/dL indicates severe renal impairment, which requires immediate attention before administering ciprofloxacin. Elevated serum creatinine levels suggest decreased kidney function, and giving ciprofloxacin can further harm the kidneys. Monitoring and addressing renal function are crucial to prevent worsening of renal impairment and potential drug toxicity. The temperature, blood pressure, and heart rate are important parameters to assess, but in this scenario, the priority is to address the severe renal impairment before proceeding with ciprofloxacin administration.

2. A client with heart failure is prescribed furosemide (Lasix). Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 100/60 mmHg
• C. Presence of a new murmur
• D. Crackles in the lungs

Correct answer: D

Rationale: The correct answer is D: Crackles in the lungs. Crackles indicate fluid overload in the lungs, a critical sign in a client with heart failure. This finding suggests that the furosemide may not be effectively managing the fluid balance, and immediate intervention is required. Choices A, B, and C are not immediate concerns in this scenario. A heart rate of 60 beats per minute, a blood pressure of 100/60 mmHg, and the presence of a new murmur are findings that may require monitoring or intervention but are not as urgent as crackles in the lungs in a client with heart failure.

3. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

• A. Evaluate the oxygen saturation.
• B. Administer a bronchodilator.
• C. Assist the client to sit upright.
• D. Encourage slow, deep breathing.

Correct answer: A

Rationale: In this scenario, the nurse should first evaluate the oxygen saturation. This action is crucial as it provides immediate information on the client's respiratory status. Assessing the oxygen saturation can help determine the adequacy of oxygenation and guide further interventions. Administering a bronchodilator (Choice B) may be necessary based on assessment findings, but it should not be the first action without knowing the oxygen saturation level. While assisting the client to sit upright (Choice C) is generally beneficial for respiratory function, in this case, assessing oxygen saturation takes precedence. Encouraging slow, deep breathing (Choice D) can be helpful, but it is secondary to evaluating the oxygen saturation in this situation.

4. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding requires immediate intervention?

• A. Barrel-shaped chest
• B. Use of accessory muscles
• C. Oxygen saturation of 85%
• D. Inspiratory crackles

Correct answer: C

Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.

5. While auscultating a client's heart sounds, which description should the nurse use to document a swishing sound related to blood turbulence or valvular defect?

• A. S1 S2
• B. S1 S2 S3
• C. Murmur
• D. Pericardial friction rub

Correct answer: C

Rationale: The correct answer is 'C: Murmur.' A murmur is auscultated as a swishing sound associated with blood turbulence caused by the heart or a valvular defect. Choices 'A: S1 S2' and 'B: S1 S2 S3' refer to normal heart sounds, specifically the closure of heart valves. 'D: Pericardial friction rub' is a dry, rubbing or grating sound caused by inflammation of the pericardial sac and is not associated with blood flow or valvular issues.

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