Nursing Elites

1. What is the priority nursing assessment for a patient with chronic kidney disease?

• A. Monitor serum creatinine
• B. Monitor blood pressure
• C. Monitor urine output
• D. Monitor potassium levels

Correct answer: A

Rationale: The correct answer is to monitor serum creatinine. In patients with chronic kidney disease, monitoring serum creatinine is crucial as it reflects kidney function. This assessment helps healthcare providers in evaluating the progression of the disease and adjusting treatment plans accordingly. Monitoring blood pressure (choice B) is essential in managing chronic kidney disease, but monitoring serum creatinine takes precedence. Monitoring urine output (choice C) and potassium levels (choice D) are also important aspects of managing chronic kidney disease, but they are not the priority assessment compared to monitoring serum creatinine.

2. A nurse in a mental health facility is caring for a client who is angry and throwing objects at staff members. Which of the following actions should the nurse take?

• A. Ask the client to identify what made them angry.
• B. Instruct the client to calm down.
• C. Place the client in seclusion.
• D. Encourage the client to attend group therapy.

Correct answer: C

Rationale: During a situation where a client is exhibiting violent behavior like throwing objects and posing a risk to themselves and others, the immediate priority is to ensure the safety of all involved. Placing the client in seclusion is a necessary intervention to prevent harm and allow for de-escalation. Asking the client to identify the trigger or instructing them to calm down may not be effective or safe in this escalated state. Encouraging the client to attend group therapy is not suitable when they are in an agitated and aggressive state that requires immediate intervention.

3. A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy?

• A. Varicella vaccine.
• B. Inactivated polio vaccine.
• C. Tetanus diphtheria and acellular pertussis vaccine.
• D. Inactivated influenza vaccine.

Correct answer: C

Rationale: The correct answer is C: Tetanus diphtheria and acellular pertussis (Tdap) vaccine. The Tdap vaccine can be safely administered during pregnancy to protect both the mother and the newborn against whooping cough. Choices A, B, and D are incorrect because the Varicella vaccine, Inactivated polio vaccine, and Inactivated influenza vaccine are generally not recommended during pregnancy due to safety concerns.

4. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

• A. Encourage the client to increase fluid intake.
• B. Suction the client every 2 hours.
• C. Perform chest physiotherapy every 8 hours.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

5. A client with heart failure is receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min.
• B. Vision changes.
• C. Respiratory rate of 16/min.
• D. Blood pressure of 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B: Vision changes. Vision changes are a classic sign of digoxin toxicity and should be reported immediately to the provider for further evaluation and management. A heart rate of 78/min, a respiratory rate of 16/min, and a blood pressure of 120/80 mm Hg are within normal ranges and are not typically associated with digoxin toxicity. Therefore, they would not be the priority findings to report in this situation.

Similar Questions