Nursing Elites

1. A nurse is preparing to administer medications to four clients. The nurse should administer medications to which client first?

• A. A client who has pneumonia and a WBC count of 11,500/mm3 prescribed piperacillin
• B. A client who has renal failure and a serum potassium of 5.8 mEq/L prescribed sodium polystyrene sulfonate
• C. A client who is post-coronary artery bypass graft (CABG) prescribed atorvastatin
• D. A client who has anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa

Correct answer: B

Rationale: The correct answer is B. The client with renal failure and high potassium levels requires immediate attention because hyperkalemia can lead to life-threatening cardiac complications. Administering sodium polystyrene sulfonate helps lower the potassium levels. Choice A, the client with pneumonia and a high WBC count, although important, does not present an immediate life-threatening condition. Choice C, the post-CABG client prescribed atorvastatin, and Choice D, the client with anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa, do not require immediate intervention compared to managing hyperkalemia in a client with renal failure.

2. 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.

3. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?

• A. Report any sign of infection to the provider immediately
• B. Expect your blood pressure to increase
• C. Easy bruising may occur while taking this medication
• D. Muscle rigidity is an expected adverse effect during the first few days of therapy

Correct answer: A

Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.

4. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

• A. Loud volume of the television set
• B. Wall-to-wall carpet in the living room
• C. Low chairs without armrests
• D. Use of indirect lighting

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.

5. A nurse manager is asked to select clients for early discharge from the unit following a mass casualty event. Which of the following clients should the nurse manager recommend?

• A. A client awaiting a screening colonoscopy later that day
• B. A client whose discharge was cancelled the prior day because they developed respiratory distress
• C. A client who is 6 hr postoperative following an open cholecystectomy
• D. A client who is prescribed gastric lavage treatments to treat acute aspirin toxicity

Correct answer: A

Rationale: The nurse manager should recommend the client awaiting a screening colonoscopy later that day for early discharge following a mass casualty event. This client is stable and not in immediate need of hospital care. Choices B, C, and D involve clients who require ongoing monitoring and care due to recent developments or treatments, making them unsuitable for early discharge during a mass casualty event.

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