Nursing Elites

1. A nurse is caring for a client who has congestive heart failure. Which of the following prescriptions from the provider should the nurse anticipate?

• A. Call the provider if the client’s respiratory rate is less than 18/min
• B. Administer 500 mL IV bolus of 0.9% sodium chloride over 1 hour
• C. Administer enalapril 2.5 mg PO twice daily
• D. Call the provider if the client’s pulse rate is less than 80/min

Correct answer: C

Rationale: The correct answer is C. Enalapril is an ACE inhibitor commonly prescribed for clients with congestive heart failure to help reduce blood pressure and fluid overload. Option A is incorrect as in congestive heart failure, a lower respiratory rate could be a sign of worsening condition and needs immediate attention rather than waiting to call the provider. Option B is incorrect as administering a large IV bolus of sodium chloride could exacerbate fluid overload in a client with heart failure. Option D is incorrect as a pulse rate lower than 80/min may not necessarily indicate a problem in a client with congestive heart failure.

2. A nurse is planning care for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?

• A. Clamp the chest tube intermittently.
• B. Keep the drainage system below chest level.
• C. Empty the drainage chamber every 4 hours.
• D. Apply sterile gauze around the insertion site daily.

Correct answer: B

Rationale: To ensure proper functioning of a chest tube, the nurse should keep the drainage system below chest level. This position allows for proper drainage by gravity and prevents backflow into the pleural space. Clamping the chest tube intermittently can lead to a buildup of pressure and should be avoided. Emptying the drainage chamber every 4 hours is important but not directly related to maintaining the chest tube's function. Applying sterile gauze around the insertion site daily is essential for infection prevention but does not specifically ensure the proper functioning of the chest tube.

3. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following should the nurse assess for?

• A. Respiratory rate
• B. Chest pain
• C. Use of accessory muscles
• D. Oxygen saturation

Correct answer: C

Rationale: In a client with COPD, the nurse should assess for the use of accessory muscles. This is important because COPD can lead to increased work of breathing, causing the client to engage accessory muscles to help with respiration. Assessing for the use of accessory muscles provides crucial information about the client's respiratory effort. Respiratory rate (Choice A) is a standard assessment parameter but may not specifically indicate the severity of COPD. Chest pain (Choice B) is not typically associated with COPD unless there are complicating factors. Oxygen saturation (Choice D) is essential to monitor in COPD clients, but assessing for the use of accessory muscles takes priority as it directly reflects the client's respiratory status in COPD.

4. A client is prescribed metronidazole for a bacterial infection. Which of the following should the nurse teach the client?

• A. Avoid alcohol while taking this medication
• B. It is safe to take during pregnancy
• C. Monitor for increased appetite
• D. It can cause hair loss

Correct answer: A

Rationale: The correct answer is A: 'Avoid alcohol while taking this medication.' Metronidazole can cause a disulfiram-like reaction with alcohol, leading to symptoms like nausea, vomiting, flushing, and headache. Therefore, clients should be instructed to avoid alcohol consumption. Choice B is incorrect because metronidazole is not considered safe during pregnancy, especially in the first trimester. Choice C is incorrect as metronidazole is not known to cause increased appetite. Choice D is also incorrect as hair loss is not a common side effect of metronidazole.

5. A client with lactose intolerance, who has eliminated dairy products from the diet, should increase consumption of which of the following foods?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is the correct answer because it is a good source of calcium, which is important for clients with lactose intolerance who are not consuming dairy products. Peanut butter, ground beef, and carrots do not provide as much calcium as spinach and are not the best choices for meeting the calcium needs of clients with lactose intolerance.

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