Nursing Elites

1. A case manager at an assisted living facility is reviewing the use of complementary health practices by several clients. Which of the following actions should the case manager plan to take?

• A. Plan to report a client's use of echinacea to the provider as a contraindication to aspirin therapy
• B. Plan to schedule time for a new client to continue tai chi practice as a stress reduction technique
• C. Tell a client that yoga has not been proven effective to reduce manifestations of menopause
• D. Tell a client who drinks cranberry juice daily that it can help treat existing urinary tract infections

Correct answer: B

Rationale: The correct answer is B. Tai chi is a recognized complementary health practice for stress reduction. Scheduling time for a new client to continue tai chi practice aligns with supporting holistic care. Choice A is incorrect because reporting a client's use of echinacea as a contraindication to aspirin therapy is not necessary without further context or evidence of interactions. Choice C is wrong because yoga can indeed be effective in reducing manifestations of menopause. Choice D is also incorrect because while cranberry juice is known to help prevent urinary tract infections, it is not typically used to treat existing infections.

2. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

• A. Closes the door to the client's room
• B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
• C. Measures the client's vital signs routinely
• D. Asks a group of personnel in the hall to speak quietly

Correct answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

3. A healthcare provider orders a medication dose three times higher than usual. What is the nurse's first step?

• A. Administer the medication but monitor the patient closely.
• B. Verify the dosage with the prescribing provider.
• C. Administer a lower dose to minimize the risk.
• D. Hold the medication and wait for further clarification.

Correct answer: B

Rationale: The correct answer is B: Verify the dosage with the prescribing provider. When faced with an unusual medication dose, the nurse's initial action should be to confirm the order with the healthcare provider who prescribed it. This step is crucial to prevent medication errors and ensure patient safety. Choices A, C, and D are incorrect because administering the medication without clarification, administering a lower dose without approval, or holding the medication without consulting the provider can all pose risks to the patient's well-being.

4. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin IV every 8 hours. Which of the following serum laboratory results should the nurse report to the provider before administering the gentamicin?

• A. Hematocrit 45%
• B. Sodium 140 mEq/L
• C. Creatinine 2.4 mg/dL
• D. Potassium 4.0 mEq/L

Correct answer: C

Rationale: An elevated creatinine level indicates potential kidney dysfunction, which is crucial when administering gentamicin as it can be nephrotoxic. Reporting a high creatinine level to the provider is essential to prevent further kidney damage. Choice A (Hematocrit 45%) is within the normal range and not directly related to gentamicin administration. Choice B (Sodium 140 mEq/L) and Choice D (Potassium 4.0 mEq/L) are also within normal limits and do not directly impact the administration of gentamicin.

5. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?

• A. Report any urine output greater than 30 mL/hr.
• B. Bruising on the arms and legs.
• C. Positive Trousseau's sign.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.

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