Nursing Elites

1. A client is admitted with a diagnosis of pneumonia and is receiving IV antibiotics. Which assessment finding indicates that the treatment is effective?

• A. Client reports less chest pain.
• B. Client's white blood cell count is decreasing.
• C. Client has a decreased respiratory rate.
• D. Client has clear breath sounds.

Correct answer: D

Rationale: The correct answer is D. Clear breath sounds indicate that the pneumonia is resolving and the treatment is effective. Breath sounds are often muffled or crackling in pneumonia due to the presence of fluid or inflammation in the lungs. Clear breath sounds suggest that the air is moving freely through the lungs, indicating improvement. Choices A, B, and C are less specific indicators of pneumonia resolution. While less chest pain and a decreasing white blood cell count can be positive signs, they are not as direct in indicating the effectiveness of pneumonia treatment as the presence of clear breath sounds. A decreased respiratory rate could be seen in various conditions and may not solely indicate the resolution of pneumonia.

2. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent, and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, 'She says it is OK.' What action should the nurse take next?

• A. Ask for a full explanation from the interpreter of the witnessed discussion.
• B. Have the client sign the consent form.
• C. Document the conversation and witness the consent.
• D. Ask the client directly if she has any questions.

Correct answer: A

Rationale: The correct action for the nurse to take next is to ask for a full explanation from the interpreter of the witnessed discussion. Verbal consent is not sufficient; it is crucial to ensure that the client fully comprehends the risks and benefits of the surgical procedure. By asking the interpreter to provide a detailed explanation of the discussion, the nurse can confirm that the client has given informed consent. Having the client sign the consent form (Choice B) without ensuring complete understanding may lead to potential misunderstandings. Documenting the conversation and witnessing the consent (Choice C) is not enough to guarantee the client's comprehension. Asking the client directly if she has any questions (Choice D) may not be effective if language barriers persist.

3. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

• A. Digitally check the client for a fecal impaction
• B. Administer a laxative to stimulate bowel movement
• C. Increase fluid intake to soften stool
• D. Perform a digital rectal examination

Correct answer: A

Rationale: The correct action for the nurse to implement is to digitally check the client for a fecal impaction. In this scenario, the client's presentation of frequent small amounts of liquid stool after a period of no bowel movement suggests a possible impaction. By performing a digital examination, the nurse can assess for the presence of a blockage that may be causing the symptoms. Administering a laxative (Choice B) without assessing for impaction can worsen the situation. Increasing fluid intake (Choice C) is generally beneficial for bowel health but may not address the immediate issue of a potential impaction. Performing a digital rectal examination (Choice D) is similar to Choice A but is more focused on assessing the rectum itself rather than checking for an impaction.

4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client's telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take?

• A. Administer the Toprol immediately and monitor the client until the heart rate increases.
• B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client's BP q30 minutes.
• C. Give the Toprol as scheduled if the client's systolic blood pressure reading is greater than 180.
• D. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.

Correct answer: D

Rationale: In clients with second-degree heart block, beta blockers such as metoprolol (Toprol SR) are contraindicated as they can further decrease the heart rate. Administering metoprolol in this situation can lead to serious complications. The correct action for the nurse to take is to hold the scheduled dose of Toprol and promptly notify the healthcare provider of the telemetry pattern. This ensures patient safety and appropriate management of the cardiac condition. Choices A, B, and C are incorrect because administering Toprol despite the heart block can worsen the condition and pose a risk to the client's health.

5. The nurse observes an adolescent client preparing to administer a prescribed corticosteroid medication using a metered dose inhaler. What action should the nurse take?

• A. Remind the client to hold their breath after inhaling the medication
• B. Confirm that the client has correctly shaken the inhaler
• C. Affirm that the client has correctly positioned the inhaler
• D. Ask the client if they have a spacer to use for this medication

Correct answer: A

Rationale: Corrected Rationale: Reminding the client to hold their breath after inhaling the medication is crucial as it helps ensure the medication is absorbed into the lungs. Option B is incorrect because shaking the inhaler is not directly related to the client's inhalation technique. Option C is incorrect as correct positioning of the inhaler is important but not the immediate action needed in this situation. Option D is incorrect as asking about the spacer is not the most relevant action to take at this moment.

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