Nursing Elites

1. What is the most important assessment for a patient with suspected pneumonia?

• A. Monitor lung sounds
• B. Check oxygen saturation
• C. Assess for cough
• D. Assess for fever

Correct answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

2. A client who is taking phenytoin is being taught about contraceptive options. Which of the following statements should the nurse make?

• A. You should use a backup method of birth control while taking phenytoin.
• B. Phenytoin can decrease the effectiveness of oral contraceptives.
• C. You should stop taking phenytoin while using oral contraceptives.
• D. Phenytoin can increase the effectiveness of oral contraceptives.

Correct answer: B

Rationale: The correct answer is B. Phenytoin can decrease the effectiveness of oral contraceptives, so it is important to inform the client about this interaction. Using an additional form of contraception, such as a backup method, is recommended to ensure adequate protection against pregnancy. Choice A is incorrect because it lacks specificity about the decrease in effectiveness of oral contraceptives caused by phenytoin. Choice C is incorrect as it suggests stopping phenytoin use while using oral contraceptives, which is not the appropriate action. Choice D is incorrect as phenytoin is known to decrease, not increase, the effectiveness of oral contraceptives.

3. A nurse is caring for a client who is 12 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Respiratory rate of 16/min.
• C. Heart rate of 90/min.
• D. WBC count of 15,000/mm3.

Correct answer: D

Rationale: A WBC count of 15,000/mm3 is elevated, which may indicate infection, a common concern postoperatively. An elevated WBC count suggests the body is fighting an infection, and prompt reporting to the provider is essential for further evaluation and treatment. Serosanguineous drainage on the surgical dressing is expected in the immediate postoperative period, respiratory rate of 16/min is within the normal range, and a heart rate of 90/min is also within an acceptable range postoperatively. Therefore, these findings do not raise immediate concerns that necessitate reporting to the provider.

4. A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?

• A. Use three-pronged grounded plugs
• B. Cover extension cords with a rug
• C. Check for tingling sensations around the cord to ensure the electricity is working
• D. Remove the plug from the socket by pulling the cord

Correct answer: A

Rationale: The correct answer is A: 'Use three-pronged grounded plugs.' This is important in preventing electrical fires as it provides a grounded connection, reducing the risk of electrical malfunctions. Choice B is incorrect because covering extension cords with a rug can lead to overheating and increase the risk of fire. Choice C is also incorrect as tingling sensations around a cord indicate an electrical hazard, not proper functioning. Choice D is incorrect as pulling the cord to remove a plug can damage the cord, leading to potential electrical dangers.

5. A client with thrombocytopenia is receiving care from a nurse. Which of the following actions should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving the client raw vegetables.

Correct answer: C

Rationale: In a client with thrombocytopenia, the platelet count is low, leading to a risk of bleeding. Providing a stool softener is essential to prevent constipation and straining during bowel movements, which can reduce the risk of bleeding episodes. Encouraging the client to floss daily (Choice A) is a good oral hygiene practice but is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is related to infection control but does not address the specific risk of bleeding in thrombocytopenia. Avoiding serving the client raw vegetables (Choice D) is important in clients with neutropenia to prevent infections, not in thrombocytopenia.

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