Nursing Elites

1. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?

• A. Administer the antibiotic immediately
• B. Obtain a sputum culture
• C. Notify the provider of the prescription
• D. Check the client's allergy history

Correct answer: B

Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.

2. A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?

• A. Sit the client upright
• B. Stop the TPN infusion
• C. Turn the client on their left side
• D. Prepare to add insulin to the TPN infusion

Correct answer: B

Rationale: The correct action for the nurse to take when finding that the TPN solution is infusing too rapidly is to stop the TPN infusion. This is crucial to prevent fluid overload and ensure the client's safety. Sitting the client upright (Choice A) or turning the client on their left side (Choice C) are not appropriate responses to a rapidly infusing TPN solution and do not address the immediate issue of preventing complications from the rapid infusion. Adding insulin to the TPN infusion (Choice D) is not indicated unless specifically prescribed by the healthcare provider for the client's condition. Therefore, the priority action is to stop the TPN infusion to prevent potential harm.

3. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?

• A. Encourage the patient to take deep breaths.
• B. Assist the patient to sit down slowly.
• C. Instruct the patient to use a walker for support.
• D. Teach the patient how to change positions safely.

Correct answer: B

Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.

4. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?

• A. Provide cognitive-behavioral therapy
• B. Offer frequent orientation and reassurance
• C. Administer a sedative to improve memory recall
• D. Refer the client to a neurologist for further evaluation

Correct answer: B

Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.

5. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

• A. Check for orthostatic hypotension
• B. Use a gait belt
• C. Position the chair on the strong side
• D. Ask for assistance

Correct answer: A

Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.

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