Nursing Elites

1. A nurse is assessing a client with pneumonia. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased respiratory rate
• C. Decreased temperature
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Increased respiratory rate. In pneumonia, the body tries to compensate for the reduced ability to oxygenate the blood by increasing the respiratory rate. This helps to improve oxygen exchange. Bradycardia (Choice A) is not typically associated with pneumonia, as an increased heart rate is more common due to the stress on the body. Decreased temperature (Choice C) is not a typical finding in pneumonia, as infections usually cause a fever. Elevated blood pressure (Choice D) is not a common finding in pneumonia unless there are complications such as sepsis.

2. A nurse is preparing to administer furosemide 4 mg/kg/day PO divided into 2 equal doses daily to a toddler who weighs 22 lb. How many mg should the nurse administer per dose?

• A. 10 mg
• B. 20 mg
• C. 30 mg
• D. 40 mg

Correct answer: B

Rationale: To calculate the correct dose, first, convert the toddler's weight from pounds to kilograms: 22 lb / 2.2 lb/kg = 10 kg. Next, multiply the weight in kilograms by the dosage: 4 mg/kg x 10 kg = 40 mg/day. Since the total daily dose is divided into 2 equal doses, each dose would be 20 mg. Therefore, the correct answer is 20 mg. Choice A (10 mg) is incorrect because it does not account for the correct weight-based dosage. Choice C (30 mg) and Choice D (40 mg) are incorrect as they do not correctly calculate the dose based on the weight of the toddler and the prescribed dosage per kg.

3. A client in labor has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?

• A. Polyuria
• B. Hypertension
• C. Pruritus
• D. Dry mouth

Correct answer: C

Rationale: Pruritus is a common adverse effect of epidural anesthesia, often due to the opioids administered with the epidural. It presents as itching on the skin and can cause significant discomfort to the client. Polyuria (excessive urination) and dry mouth are not typical adverse effects of epidural anesthesia. Hypertension is not commonly associated with epidural anesthesia; in fact, hypotension is a more frequent complication due to sympathetic blockade. Therefore, the correct answer is pruritus (choice C), as it is a known adverse effect of epidural anesthesia.

4. A nurse is preparing to administer a dose of digoxin. Which of the following should the nurse do first?

• A. Assess blood pressure
• B. Check heart rate
• C. Monitor potassium levels
• D. Review the medication order

Correct answer: B

Rationale: The correct answer is to check the heart rate first before administering digoxin. Digoxin is a medication that directly affects the heart, so it is crucial to ensure that the heart rate is within the appropriate range before giving the dose. If the heart rate is below 60 bpm, administering digoxin could lead to toxicity. Assessing blood pressure (Choice A) is important but not the first priority when preparing to administer digoxin. Monitoring potassium levels (Choice C) is also crucial for patients on digoxin, but it is not the initial step. Reviewing the medication order (Choice D) is necessary but can be done after checking the heart rate.

5. A client in respiratory distress who is on oxygen is being cared for by a nurse. What is the most appropriate short-term goal?

• A. Nasal cannula remains in place
• B. Client completes morning care
• C. Client verbalizes breathing improvement after lunch
• D. Client maintains oxygen saturation of 90% during the shift

Correct answer: D

Rationale: The correct answer is D because maintaining oxygen saturation of 90% is a specific, measurable short-term goal that ensures adequate oxygenation. Choice A is not a goal focused on the client's physiological status but rather on the equipment. Choice B is related to activities of daily living and does not address the respiratory distress issue. Choice C is subjective and may not reflect the actual physiological improvement in the client's condition.

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