Nursing Elites

1. A nurse in an emergency department is caring for a client who reports cocaine use 1 hour ago. Which of the following findings should the nurse expect?

• A. Hypotension.
• B. Memory loss.
• C. Slurred speech.
• D. Elevated temperature.

Correct answer: D

Rationale: The correct answer is D: Elevated temperature. Cocaine is a stimulant drug that can lead to increased body temperature. Hypotension (Choice A) is less likely as cocaine tends to elevate blood pressure. Memory loss (Choice B) and slurred speech (Choice C) are more commonly associated with depressant drugs rather than stimulant drugs like cocaine.

2. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the healthcare professional take first?

• A. Check the residual volume.
• B. Flush the tube with 0.9% sodium chloride.
• C. Elevate the head of the bed to 45 degrees.
• D. Warm the formula to body temperature.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees is the priority action before administering an enteral feeding through an NG tube. This position helps prevent aspiration by promoting proper flow and digestion of the feeding. Checking the residual volume, flushing the tube, and warming the formula are important steps but come after ensuring the client is in the correct position to minimize the risk of complications.

3. A healthcare professional is preparing to administer an IV fluid bolus of 500 mL over 4 hours to a client who is dehydrated. The healthcare professional should set the IV pump to deliver how many mL/hr?

• A. 75 mL/hr.
• B. 100 mL/hr.
• C. 125 mL/hr.
• D. 150 mL/hr.

Correct answer: C

Rationale: Setting the IV pump to 125 mL/hr ensures the correct infusion rate for delivering 500 mL over 4 hours. To calculate the mL/hr rate, divide the total volume to be infused (500 mL) by the total time for infusion (4 hours): 500 mL / 4 hours = 125 mL/hr. Choice A (75 mL/hr) is too low and would result in an insufficient infusion rate, potentially delaying fluid resuscitation. Choice B (100 mL/hr) would also be too low and not deliver the fluid within the specified time frame. Choice D (150 mL/hr) is too high and would infuse the fluid too quickly, potentially causing fluid overload and complications.

4. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

• A. Vomiting.
• B. Hypertension.
• C. Epigastric pain.
• D. Contractions.

Correct answer: D

Rationale: Following an amniocentesis at 33 weeks of gestation, the nurse should monitor the client for contractions. Contractions can indicate preterm labor, which requires immediate attention. Vomiting, hypertension, and epigastric pain are not typically associated with amniocentesis complications at this gestational age.

5. A nurse is preparing to administer a dose of vancomycin IV to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse take?

• A. Administer the medication over 15 minutes.
• B. Monitor the client's urine output every 8 hours.
• C. Check the client's creatinine level before administering the medication.
• D. Assess the client for a history of allergies to antibiotics.

Correct answer: C

Rationale: The correct action for the nurse to take is to check the client's creatinine level before administering vancomycin. Vancomycin is known to be nephrotoxic, so assessing the client's renal function before administering the medication is crucial to prevent further kidney damage. Administering the medication over 15 minutes (Choice A) is not the priority in this scenario as renal function assessment takes precedence. Monitoring urine output (Choice B) is important for assessing renal function but checking creatinine level directly provides more accurate information. Assessing for allergies to antibiotics (Choice D) is also important but not as essential as checking the creatinine level due to the nephrotoxic nature of vancomycin.

Similar Questions