Nursing Elites

1. A nurse is caring for a client with a new prescription for atorvastatin. Which of the following should the nurse monitor?

• A. Liver function tests
• B. Potassium levels
• C. Blood glucose levels
• D. Serum calcium levels

Correct answer: A

Rationale: The correct answer is A: Liver function tests. Atorvastatin, a medication commonly used to lower cholesterol levels, can potentially cause liver damage as a side effect. Monitoring liver function tests is essential to detect any abnormalities early. Choices B, C, and D are incorrect because atorvastatin is not known to directly impact potassium levels, blood glucose levels, or serum calcium levels. While these parameters may be monitored for other reasons, the priority when administering atorvastatin is to monitor liver function due to the risk of hepatotoxicity.

2. A nurse is caring for a client with a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

• A. Tidaling with spontaneous respirations
• B. Drainage collection chamber is 1/3 full
• C. 1 cm of water present in the water seal chamber
• D. Suction chamber pressure of -20 cm H2O

Correct answer: C

Rationale: 1 cm of water in the water seal chamber is insufficient to ensure proper functioning of the chest tube. The water seal chamber typically requires a water level of 2 cm. Tidaling with spontaneous respirations (choice A) is an expected finding indicating proper functioning. Having the drainage collection chamber 1/3 full (choice B) is within the normal range. A suction chamber pressure of -20 cm H2O (choice D) is an appropriate level for chest tube drainage.

3. A nurse is planning a staff education program to review nursing interventions for patients who have kidney failure. What source should the nurse identify as the best source for obtaining evidence-based practice information?

• A. A recent peer-reviewed nursing research article
• B. A website for a nursing association
• C. A textbook published 5 years ago
• D. An expert opinion from a seasoned nurse

Correct answer: A

Rationale: The correct answer is A: A recent peer-reviewed nursing research article. Peer-reviewed research articles provide the most current and reliable evidence-based practice information for clinical care. Choice B, a website for a nursing association, may have valuable information but may not always guarantee the highest level of evidence. Choice C, a textbook published 5 years ago, may not reflect the most up-to-date practices and guidelines. Choice D, an expert opinion from a seasoned nurse, though valuable, is not as reliable as evidence derived from peer-reviewed research articles.

4. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?

• A. Administer antiseizure medications promptly.
• B. Use oral airway devices during seizures.
• C. Pad the side rails of the bed.
• D. Apply restraints during the seizure to prevent injury.

Correct answer: C

Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.

5. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

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