Nursing Elites

1. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

• A. Call the health care provider immediately
• B. Administer acetaminophen as ordered as this is normal at this time
• C. Send blood, urine, and sputum for culture
• D. Increase the client's fluid intake

Correct answer: B

Rationale: In this scenario, the nurse should administer acetaminophen as ordered because a slight fever is normal after an MI. This intervention can help manage the fever unless other complications are present. Calling the health care provider immediately is not necessary for a slight fever post-MI. Sending blood, urine, and sputum for culture is not indicated solely based on a slight fever without other symptoms or signs of infection. Increasing fluid intake may be beneficial for various reasons but is not the priority in this situation where managing the fever with acetaminophen is appropriate.

2. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?

• A. I have a sharp pain in my chest when I take a breath.
• B. I have been coughing up foul-tasting, brown, thick sputum.
• C. I have been sweating all day.
• D. I feel hot off and on.

Correct answer: B

Rationale: Coughing up foul-tasting, brown, thick sputum suggests a possible abscess or secondary infection, requiring attention. Choice A may indicate pleurisy, but the focus should be on the sputum. Choice C may be non-specific and could be related to the infection or fever. Choice D is non-specific and may be expected during an infection.

3. A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements by the nurse is appropriate?

• A. Use sugar-free gum if you experience a metallic taste in your mouth.
• B. Drink fluids at mealtime to prevent early satiety.
• C. Foods that are higher in fat can help nausea.
• D. Raw fruits and vegetables will be easier for your body to digest.

Correct answer: A

Rationale: The correct answer is A. Using sugar-free gum can help alleviate the metallic taste often experienced during chemotherapy treatments. Choices B, C, and D are incorrect. Drinking fluids at mealtime may worsen early satiety, foods higher in fat can exacerbate nausea, and raw fruits and vegetables may be harder for the body to digest and may pose a risk of infection for individuals with compromised immune systems.

4. The nurse is providing care for a client with a new tracheostomy. Which of these assessments is a priority?

• A. Checking the client's oxygen saturation level
• B. Monitoring the client's pain level
• C. Checking the tracheostomy site for signs of infection
• D. Monitoring the client's level of consciousness

Correct answer: C

Rationale: When caring for a client with a new tracheostomy, the priority assessment is checking the tracheostomy site for signs of infection. This is essential to detect early signs of complications such as infection, which can lead to serious issues. Monitoring oxygen saturation is important but not as critical as ensuring the tracheostomy site is free from infection. Pain assessment and level of consciousness are also important but secondary to assessing for signs of infection in this scenario.

5. A client with a history of seizures is being monitored with an electroencephalogram (EEG). Which of these interventions should the nurse perform to prepare the client for the test?

• A. Instruct the client to avoid caffeine for 8 hours before the test
• B. Explain the procedure to the client and obtain consent
• C. Administer anticonvulsant medication as ordered
• D. Instruct the client to wash their hair the morning of the test

Correct answer: A

Rationale: Instructing the client to avoid caffeine for 8 hours before the EEG is essential. This intervention helps ensure accurate test results by preventing stimulation of the nervous system, which could interfere with the interpretation of the brain's electrical activity. Explaining the procedure and obtaining consent are important steps but do not directly impact the test results. Administering anticonvulsant medication as ordered is a medical intervention and not a preparation step for the test. Instructing the client to wash their hair the morning of the test is not necessary for EEG preparation.

Similar Questions