Nursing Elites

1. A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?

• A. Administer an antihistamine as prescribed.
• B. Stop the infusion and notify the healthcare provider.
• C. Slow the infusion rate and monitor the client.
• D. Administer epinephrine subcutaneously.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.

2. The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?

• A. Calcium level
• B. Sodium level
• C. Magnesium level
• D. Potassium level

Correct answer: D

Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.

3. A client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). What should the nurse monitor for?

• A. Monitor for signs of liver toxicity.
• B. Assess for gastrointestinal side effects, such as nausea or diarrhea.
• C. Monitor for signs of infection, such as fever or sore throat.
• D. Administer DMARDs with meals to prevent gastrointestinal upset.

Correct answer: C

Rationale: Correct Answer: Monitoring for signs of infection, such as fever or sore throat, is crucial when a client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). DMARDs can suppress the immune system, making individuals more susceptible to infections. Early detection of infections allows for prompt treatment and helps prevent complications. Choices A, B, and D are incorrect because while liver toxicity and gastrointestinal side effects are possible side effects of DMARDs, monitoring for signs of infection takes priority due to the increased risk of infections associated with these medications.

4. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

• A. CAGE is a tool for general substance abuse screening.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response does not indicate alcohol addiction.
• D. All four responses must be positive to suggest alcohol dependence.

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

5. A client with psoriasis is prescribed topical corticosteroids. What side effect should the nurse monitor for?

• A. Monitor for weight gain and skin thinning.
• B. Assess for increased sensitivity to sunlight.
• C. Monitor for hair loss and excessive bruising.
• D. Report any signs of increased redness or itching.

Correct answer: D

Rationale: The correct answer is D. When a client with psoriasis is prescribed topical corticosteroids, the nurse should monitor for signs of increased redness or itching. This is because topical corticosteroids can cause skin thinning and increased redness if overused. Choices A, B, and C are incorrect because weight gain, sensitivity to sunlight, hair loss, and excessive bruising are not typically associated with the use of topical corticosteroids.

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