Nursing Elites

1. A healthcare professional is preparing to administer a dose of nitroglycerin. Which of the following should be assessed first?

• A. Blood pressure
• B. Heart rate
• C. Pain level
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is to assess blood pressure first before administering nitroglycerin. Nitroglycerin is a vasodilator that can cause a sudden drop in blood pressure, leading to adverse effects such as dizziness or fainting. Assessing blood pressure before administration helps determine if the patient's blood pressure is within the acceptable range for nitroglycerin administration. Heart rate, pain level, and respiratory rate are also important assessments, but blood pressure should take precedence due to the vasodilating effects of nitroglycerin.

2. A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?

• A. Administer it intramuscularly
• B. Monitor APTT levels
• C. Give it in the abdomen
• D. Administer rapidly

Correct answer: C

Rationale: The correct answer is to give enoxaparin in the abdomen. Enoxaparin is usually administered subcutaneously in the abdomen to avoid muscle irritation. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice B is incorrect as monitoring APTT levels is not directly related to administering enoxaparin. Choice D is incorrect as enoxaparin should be administered slowly to prevent bruising or bleeding at the injection site.

3. A nurse is caring for a client who is 38 weeks pregnant and has a history of herpes simplex virus 2. Which question is most appropriate for the nurse to ask?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask is whether the client has any active herpes lesions. This is crucial because the presence of active lesions can necessitate a cesarean section to prevent transmission of the virus to the newborn. Asking about membrane rupture (choice A) is important but not directly related to the client's herpes simplex virus 2 status. Inquiring about the frequency of contractions (choice B) is relevant for assessing labor progression but does not address the immediate concern of herpes transmission. Asking about being positive for beta strep (choice D) is important for determining the need for prophylactic antibiotics during labor, but it is not directly related to the client's herpes simplex virus 2 status.

4. A nurse is preparing to teach a client with chronic renal failure. Which dietary instruction is most appropriate?

• A. Increase calcium intake
• B. Increase potassium intake
• C. Increase protein intake
• D. Restrict protein intake

Correct answer: D

Rationale: The correct answer is to restrict protein intake for a client with chronic renal failure. In renal failure, the kidneys are unable to effectively filter waste products. Excessive protein intake can lead to the accumulation of waste products, increasing the workload on the kidneys. Therefore, restricting protein intake is essential to prevent further kidney damage. Choices A, B, and C are incorrect. Increasing calcium intake is not specifically indicated for chronic renal failure. Increasing potassium intake can be dangerous in renal failure as impaired kidneys may not be able to excrete excess potassium. Increasing protein intake is contraindicated in chronic renal failure as it can worsen kidney function and increase the accumulation of waste products.

5. A nurse is preparing to administer a client's first dose of a new antibiotic. Which of the following is the priority nursing action?

• A. Assess the client's allergies.
• B. Monitor the client's vital signs.
• C. Inform the client of potential side effects.
• D. Obtain the client's informed consent.

Correct answer: A

Rationale: Assessing allergies before administering a new medication is crucial as it helps prevent potentially life-threatening allergic reactions like anaphylaxis. While monitoring vital signs and informing the client of side effects are important nursing actions, assessing allergies takes precedence to ensure the client's safety. Informed consent is necessary for the treatment process, but assessing allergies is the priority before administering any new medication.

Similar Questions