Nursing Elites

1. A client with a history of seizure disorder who is receiving phenytoin (Dilantin) is being discharged. Which instruction should the nurse provide?

• A. Take the medication at bedtime.
• B. Monitor drug levels regularly.
• C. Avoid alcohol while taking this medication.
• D. Take the medication at the same time every day.

Correct answer: B

Rationale: The correct answer is to instruct the client to monitor drug levels regularly. This is crucial for phenytoin (Dilantin) to ensure that the medication levels are within the therapeutic range and to prevent toxicity. Choice A, taking the medication at bedtime, is not specifically required for phenytoin administration. Choice C, avoiding alcohol, is generally a good practice with medications but is not as critical as monitoring drug levels for phenytoin. Choice D, taking the medication at the same time every day, is important for consistency but does not address the specific monitoring needs of phenytoin.

2. The nurse is providing care for a client with a draining postoperative wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take?

• A. Encourage increased oral fluids.
• B. Provide high-protein snacks.
• C. Change the wound dressing.
• D. Administer prescribed antibiotics.

Correct answer: D

Rationale: Administering prescribed antibiotics is crucial in treating MRSA infections. MRSA is a type of bacteria that is resistant to many antibiotics, including methicillin. Therefore, prompt administration of the appropriate antibiotics is essential to target the MRSA infection effectively. Encouraging increased oral fluids (Choice A) and providing high-protein snacks (Choice B) may be beneficial for overall recovery but are not the most important actions in treating an MRSA infection. Changing the wound dressing (Choice C) is important for wound care but does not directly address the infection caused by MRSA.

3. During a home visit, a nurse finds that an elderly client is having trouble remembering to take their medications. What is the best intervention?

• A. Set up a pill organizer
• B. Involve family members in care
• C. Arrange for a home health aide
• D. Implement all of the above

Correct answer: D

Rationale: The best intervention when an elderly client is having trouble remembering to take their medications is to implement all of the above options. Setting up a pill organizer helps in organizing and remembering medication schedules. Involving family members in care ensures additional support and reminders. Arranging for a home health aide can provide direct assistance and supervision. Implementing all these strategies together can significantly improve medication adherence, especially in clients with memory issues. Each option plays a crucial role in addressing different aspects of the problem, making 'Implement all of the above' the most comprehensive and effective choice.

4. Based on the documentation in the medical record, which action should the nurse implement next?

• A. Administer the rubella vaccine subcutaneously
• B. Observe the mother breastfeeding her infant
• C. Call the nursery for the infant's blood type result
• D. Administer Vicodin one tablet for pain

Correct answer: B

Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.

5. During a health screening, a client's blood pressure reads 160/100 mm Hg. What should the nurse recommend?

• A. Schedule a follow-up appointment
• B. Start making immediate dietary changes
• C. Begin an exercise program
• D. All of the above

Correct answer: A

Rationale: A follow-up with a healthcare provider is necessary to assess and manage the newly identified hypertension. While dietary changes and exercise are important for managing high blood pressure, immediate lifestyle modifications without further evaluation by a healthcare provider may not be safe or effective. Option A is the most appropriate initial step to ensure proper assessment and management of the client's blood pressure. Therefore, choices B and C are incorrect in this scenario. Option D is also incorrect because not all options should be implemented without proper medical guidance.

Similar Questions