Nursing Elites

1. A nurse is caring for a client who has a pulmonary embolism. Which of the following findings indicates the effectiveness of the treatment?

• A. A chest x-ray reveals increased density in all lung fields.
• B. The client reports feeling less anxious.
• C. Diminished breath sounds are auscultated bilaterally.
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg.

Correct answer: B

Rationale: The correct answer is B. In a client with a pulmonary embolism, improvement in anxiety levels can indicate the effectiveness of treatment as it suggests better oxygenation and perfusion. Choices A, C, and D do not directly reflect the effectiveness of treatment for a pulmonary embolism. Increased density in all lung fields on a chest x-ray may indicate worsening of the condition, diminished breath sounds suggest impaired lung function, and ABG results with a pH of 7.48, PaO2 of 77 mm Hg, and PaCO2 of 47 mm Hg do not specifically indicate treatment effectiveness for a pulmonary embolism.

2. A healthcare provider is caring for a client who has a new prescription for enoxaparin. Which of the following actions should the healthcare provider take?

• A. Administer the medication intramuscularly.
• B. Inject the medication into the client's abdomen.
• C. Massage the injection site after administration.
• D. Aspirate for blood return before administering.

Correct answer: B

Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously into the abdomen to ensure proper absorption. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice C is incorrect because massaging the injection site after administration is not recommended for enoxaparin injections. Choice D is incorrect because aspirating for blood return is not necessary before administering a subcutaneous injection like enoxaparin.

3. A nurse is planning to administer a blood transfusion to a client. Which of the following should the nurse do to prevent an adverse transfusion reaction?

• A. Verify the client's blood type with the provider's prescription
• B. Ensure the client's consent for the transfusion is on file
• C. Administer a diuretic prior to starting the transfusion
• D. Check the client's temperature prior to the transfusion

Correct answer: A

Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.

4. Which lab value should be monitored in a patient on digoxin?

• A. Monitor potassium levels
• B. Monitor calcium levels
• C. Monitor digoxin levels
• D. Monitor sodium levels

Correct answer: C

Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.

5. A nurse is assessing a client who has a urinary tract infection and is receiving ciprofloxacin. Which of the following findings should the nurse report to the provider?

• A. Dry mouth.
• B. Photosensitivity.
• C. Headache.
• D. Urinary retention.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin can cause photosensitivity, making the client more sensitive to sunlight. It is essential for the nurse to report this finding to the provider so that appropriate measures can be taken to prevent skin damage. Dry mouth, headache, and urinary retention are not typically associated with ciprofloxacin use and do not require immediate reporting to the provider in this scenario.

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