Nursing Elites

1. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include in the plan of care?

• A. Place the client in the supine position.
• B. Perform chest percussion every 4 hours.
• C. Administer oxygen via nasal cannula.
• D. Limit fluid intake to 1,500 mL/day.

Correct answer: B

Rationale: The correct intervention for a client with pneumonia is to perform chest percussion every 4 hours. Chest percussion helps loosen secretions and improve airway clearance in clients with pneumonia. Placing the client in the supine position can worsen breathing, so it is incorrect. Administering oxygen via nasal cannula is a common intervention for clients with respiratory issues but is not specific to pneumonia. Limiting fluid intake to 1,500 mL/day may not be appropriate as pneumonia can lead to dehydration, so it is not the priority intervention.

2. A nurse is preparing to administer a dose of amoxicillin to a client who has an allergy to penicillin. Which of the following actions should the nurse take?

• A. Administer the medication as prescribed.
• B. Verify the client's allergy status before administering the medication.
• C. Ask the provider to prescribe a different antibiotic.
• D. Check the client's skin for any rashes before administering the medication.

Correct answer: C

Rationale: In this scenario, the nurse should ask the provider to prescribe a different antibiotic instead of administering amoxicillin to a client with a known penicillin allergy. Choice A is incorrect because administering amoxicillin to a client with a penicillin allergy can lead to an allergic reaction. Choice B is not the best option as simply verifying the client's allergy status does not address the potential harm of giving amoxicillin. Choice D is irrelevant as checking the client's skin for rashes does not address the issue of administering a potentially harmful medication. Therefore, the most appropriate action is to request a different antibiotic from the provider to ensure the safety of the client.

3. A client has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?

• A. Potassium
• B. Sodium
• C. Calcium
• D. Hemoglobin

Correct answer: A

Rationale: When a client is prescribed furosemide, monitoring potassium levels is crucial due to the drug's potential to cause hypokalemia. Furosemide is a loop diuretic that promotes potassium excretion in the urine, leading to a risk of low potassium levels. Monitoring potassium levels helps in detecting and preventing hypokalemia, which can result in adverse effects like cardiac dysrhythmias. Sodium, calcium, and hemoglobin levels are usually not directly affected by furosemide, making them less pertinent for monitoring in this specific scenario.

4. While caring for a client receiving a blood transfusion who reports chills, which action should the nurse take first?

• A. Stop the transfusion.
• B. Administer acetaminophen as prescribed.
• C. Notify the provider.
• D. Check the client's blood pressure.

Correct answer: A

Rationale: The correct action for the nurse to take first when a client reports chills during a blood transfusion is to stop the transfusion. Chills can indicate a transfusion reaction, which is a potentially serious situation. Stopping the transfusion immediately is crucial to prevent further complications. Administering acetaminophen or checking the client's blood pressure can come after ensuring the safety of the client by stopping the transfusion. Notifying the provider is important, but the immediate priority is to stop the transfusion.

5. How should fluid balance be monitored in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: Corrected Question: To assess fluid balance in a patient receiving diuretics, monitoring daily weight is the most accurate method. This is because diuretics primarily affect fluid levels in the body, leading to changes in weight due to fluid loss. While monitoring intake and output, checking for edema, and monitoring blood pressure are important aspects of patient care, they do not provide as direct and accurate information about fluid balance as daily weight monitoring specifically in patients on diuretics.

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