Nursing Elites

1. A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.

2. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor indicates bronchospasm, a serious reaction that can compromise the client's airway. Immediate intervention is crucial to prevent further respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone but are not as immediately life-threatening as airway compromise indicated by stridor.

3. A client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor closely?

• A. Hemoglobin
• B. White blood cell count
• C. Serum potassium
• D. Serum creatinine

Correct answer: C

Rationale: The correct answer is C: Serum potassium. When a client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen), monitoring serum potassium levels closely is crucial. Epoetin alfa stimulates red blood cell production, which can lead to an increase in potassium levels. Hyperkalemia is a potential risk in these clients. Monitoring hemoglobin levels (choice A) is important in assessing the effectiveness of epoetin alfa therapy, but it is not the laboratory value that poses an immediate risk related to the medication. White blood cell count (choice B) and serum creatinine (choice D) are not directly affected by epoetin alfa therapy and are not the priority laboratory values to monitor in this case.

4. The nurse is assessing a 1-year-old child with bronchiolitis caused by respiratory syncytial virus (RSV). Which assessment finding requires immediate intervention?

• A. Wheezing heard on expiration
• B. Oxygen saturation of 90%
• C. Respiratory rate of 40 breaths per minute
• D. Nasal flaring with sternal retractions

Correct answer: D

Rationale: Nasal flaring with sternal retractions indicates severe respiratory distress in a 1-year-old with bronchiolitis, requiring immediate intervention. Nasal flaring and sternal retractions are signs of increased work of breathing and decreased air movement, indicating the child is struggling to breathe. Wheezing on expiration (Choice A) is common in bronchiolitis but may not require immediate intervention. An oxygen saturation of 90% (Choice B) is low but may not be the most critical finding in this case. A respiratory rate of 40 breaths per minute (Choice C) is elevated but alone may not indicate the need for immediate intervention as much as nasal flaring and sternal retractions.

5. Which nursing intervention has the highest priority for a multigravida who delivered an hour ago?

• A. Maintain cold packs to the perineum for 24 hours.
• B. Assess the client's pain level frequently.
• C. Observe for appropriate interaction with the infant.
• D. Assess fundal tone and lochia flow.

Correct answer: D

Rationale: Assessing fundal tone and lochia flow is crucial in the immediate postpartum period to detect postpartum hemorrhage, a life-threatening complication. Monitoring these parameters allows for early identification of excessive bleeding, enabling prompt intervention. While maintaining cold packs to the perineum, assessing pain levels, and observing for appropriate interaction with the infant are important aspects of postpartum care, assessing fundal tone and lochia flow takes precedence due to its direct relevance to identifying and managing a potential emergency situation.

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