Nursing Elites

1. A client diagnosed with pneumonia is receiving oxygen therapy at 4 L/min via nasal cannula. Which of the following interventions is most important?

• A. Encourage fluid intake.
• B. Monitor oxygen saturation levels.
• C. Change the oxygen tubing daily.
• D. Assist with frequent position changes.

Correct answer: B

Rationale: Monitoring oxygen saturation levels is the most important intervention in this scenario. It ensures that the client is receiving adequate oxygenation, which is crucial for a client with pneumonia. By monitoring saturation levels, the nurse can promptly identify any oxygenation issues and adjust the oxygen delivery if necessary. Encouraging fluid intake, changing oxygen tubing daily, and assisting with frequent position changes are also important aspects of care for a client with pneumonia, but they are not as critical as monitoring oxygen saturation levels in ensuring immediate respiratory support.

2. A nurse is providing teaching to a client who has chronic kidney failure and an AV fistula for hemodialysis with a new prescription for epoetin alfa. Which of the following therapeutic effects of epoetin alfa should the nurse include in the teaching?

• A. Reduces blood pressure
• B. Inhibits clotting of fistula
• C. Promotes RBC production
• D. Stimulates growth of neutrophils

Correct answer: C

Rationale: The correct answer is C: Promotes RBC production. Epoetin alfa stimulates red blood cell production, which is important for clients with chronic kidney disease who may have anemia due to decreased erythropoietin production by the kidneys. Options A, B, and D are incorrect: epoetin alfa does not directly reduce blood pressure, inhibit clotting of the fistula, or stimulate growth of neutrophils.

3. A nurse is reviewing the medication metformin with a client who has diabetes. Which of the following side effects should the nurse discuss?

• A. Gastrointestinal upset
• B. Increased appetite
• C. Weight loss
• D. Frequent urination

Correct answer: A

Rationale: The correct answer is A: Gastrointestinal upset. Metformin can cause gastrointestinal upset, especially when first starting therapy. It is important to take it with food to reduce these effects. Increased appetite (choice B) and weight loss (choice C) are not common side effects of metformin but may occur due to improved blood sugar control. Frequent urination (choice D) is a symptom of uncontrolled diabetes and not a side effect of metformin.

4. A nurse is planning to delegate to an AP the task of fasting blood glucose testing for a client who has diabetes mellitus. Which of the following actions should the nurse take?

• A. Determine if the AP is qualified to perform the test
• B. Help the AP perform the blood glucose test
• C. Assign the AP to ask the client if they have taken diabetic medication today
• D. Have the AP check the medical record for prior blood glucose test results

Correct answer: A

Rationale: Before delegating any task, the nurse must determine whether the AP is qualified to perform it. In this scenario, verifying the AP's competency to conduct fasting blood glucose testing is crucial for patient safety and compliance with facility protocols. The other choices are incorrect because they do not address the essential step of assessing the AP's ability to perform the delegated task. While helping the AP or assigning tasks related to diabetic medication or medical records are important, the primary concern should be confirming the AP's competence for the specific delegated duty of blood glucose testing.

5. A nurse is caring for a client with congestive heart failure. Which of the following prescriptions should the nurse anticipate?

• A. Call the provider if the respiratory rate is less than 18/min
• B. Administer a 500 mL IV bolus of 0.9% sodium chloride over 1 hour
• C. Administer enalapril 2.5 mg PO twice daily
• D. Call the provider if the client’s pulse rate is less than 80/min

Correct answer: C

Rationale: Enalapril, an ACE inhibitor, is commonly prescribed to manage hypertension and heart failure. It helps reduce the workload on the heart and prevent fluid retention. Options A, B, and D are incorrect. Option A focuses on a respiratory rate, which is not specific to heart failure management. Option B suggests administering a large IV bolus of fluid, which can worsen heart failure by increasing fluid volume. Option D addresses the pulse rate, which is not a typical parameter to monitor for heart failure specifically.

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