Nursing Elites

1. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

• A. Ask the client about soft food preferences
• B. Auscultate the client’s breath sounds
• C. Obtain and record the client’s vital signs
• D. Determine which side of the body is weak

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

2. After medicating the client for pain and collecting granules and stones from strained urine, which action is most important for the nurse to implement next?

• A. Send the calculi for laboratory analysis of stone composition.
• B. Evaluate the client for persistent pain.
• C. Assess the clarity of urine.
• D. Encourage high fluid intake to produce urine output of 2L/day.

Correct answer: A

Rationale: Sending the calculi for analysis is crucial in determining the type of stone present. Identifying the stone composition helps in developing an effective treatment plan and preventive measures to avoid future episodes of urolithiasis. This step is essential in providing targeted care for the client. Options B, C, and D are not the most important actions at this point. While evaluating for persistent pain is essential, determining the stone composition takes precedence to guide appropriate interventions.

3. When a UAP reports to the charge nurse that a client has a weak pulse with a rate of 44 beats per minute, what action should the charge nurse implement?

• A. Instruct the UAP to count the client's apical pulse rate for sixty seconds.
• B. Determine if the UAP also measured the client's capillary refill time.
• C. Assign a practical nurse (LPN) to determine if an apical radial pulse deficit is present.
• D. Notify the health care provider of the abnormal pulse rate and pulse volume.

Correct answer: D

Rationale: The correct action for the charge nurse to implement is to notify the health care provider of the abnormal pulse rate and pulse volume. A weak pulse with bradycardia (pulse rate of 44 beats per minute) requires immediate follow-up to investigate potential underlying issues. In this situation, it is crucial to involve the healthcare provider for further assessment and intervention. Instructing the UAP to count the client's apical pulse rate for sixty seconds (Choice A) may delay necessary actions. Determining capillary refill time (Choice B) is not directly related to addressing a weak pulse, and assigning an LPN to assess an apical radial pulse deficit (Choice C) is not as urgent as involving the healthcare provider.

4. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

• A. Observe the appearance of the stool
• B. Assess the client’s skin turgor
• C. Review the client’s laboratory values
• D. Auscultate the client’s bowel sounds

Correct answer: A

Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.

5. What should the nurse monitor for during the IV infusion of vasopressin (Pitressin) in a client with bleeding esophageal varices?

• A. Vasodilatation of the extremities
• B. Chest pain and dysrhythmia
• C. Hypotension and tachycardia
• D. Decreasing GI cramping and nausea

Correct answer: B

Rationale: During the IV infusion of vasopressin in a client with bleeding esophageal varices, the nurse should monitor for chest pain and dysrhythmia. Vasopressin is a vasoconstrictor that can cause cardiovascular effects, including chest pain and dysrhythmias. Options A, C, and D are incorrect as vasopressin is not expected to cause vasodilatation of the extremities, hypotension, tachycardia, or improvements in GI symptoms such as cramping and nausea.

Similar Questions