Nursing Elites

1. A nurse is caring for a client who has a prescription for metoprolol. For which of the following findings should the nurse withhold the medication?

• A. Heart rate 56/min.
• B. Oxygen saturation 93%.
• C. Respiratory rate 18/min.
• D. Blood pressure 118/74 mm Hg.

Correct answer: A

Rationale: The correct answer is A: Heart rate 56/min. Metoprolol, a beta blocker, should be withheld if the client's heart rate is below 60/min to prevent further bradycardia. Choices B, C, and D are within normal ranges and do not indicate a need to withhold metoprolol.

2. A healthcare provider is collecting data from a client who has multiple sclerosis. Which of the following findings should the healthcare provider expect?

• A. Fever
• B. Ataxia
• C. Nystagmus
• D. Fatigue

Correct answer: B

Rationale: Ataxia, which refers to difficulty with coordination, is a common symptom seen in individuals with multiple sclerosis. Nystagmus, the involuntary eye movement, can also occur in multiple sclerosis but is not as common as ataxia. Fatigue is a common symptom in multiple sclerosis, but ataxia is more specific. Fever is not a typical finding associated with multiple sclerosis.

3. A nurse is providing dietary teaching for a client with chronic kidney disease. What should be emphasized?

• A. Increase protein intake to promote healing
• B. Limit intake of potassium and phosphorus
• C. Increase fluid intake to prevent dehydration
• D. Encourage the intake of high-sodium foods

Correct answer: B

Rationale: The correct answer is to emphasize limiting the intake of potassium and phosphorus for a client with chronic kidney disease. Excessive intake of potassium and phosphorus can lead to complications in kidney disease patients. Choice A is incorrect because increasing protein intake can put additional stress on the kidneys. Choice C is incorrect as excessive fluid intake can worsen kidney function in such clients. Choice D is incorrect as encouraging high-sodium foods can lead to fluid retention and hypertension, which are not beneficial for individuals with chronic kidney disease.

4. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer oxytocin
• B. Perform fundal massage
• C. Administer IV fluids
• D. Call the provider

Correct answer: B

Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.

5. A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?

• A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
• B. Reinforcing teaching with a client who is learning to walk with a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure ulcer

Correct answer: C

Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.

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