Nursing Elites

1. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?

• A. Administer the medication over 30 minutes.
• B. Monitor the client for a decrease in blood pressure during administration.
• C. Assess the IV site for infiltration during administration.
• D. Premedicate the client with an antiemetic prior to administration.

Correct answer: C

Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.

2. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.

3. What is the appropriate action for a patient experiencing a severe allergic reaction?

• A. Administer epinephrine
• B. Administer antihistamines
• C. Administer corticosteroids
• D. Administer oxygen

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps reverse the symptoms rapidly by constricting blood vessels, increasing heart rate, and opening airways. Antihistamines (Choice B) may help with mild allergic reactions but are not effective for severe cases. Corticosteroids (Choice C) are used to reduce inflammation and are typically not the first-line treatment for acute severe allergic reactions. Administering oxygen (Choice D) may be necessary to support breathing in severe cases, but epinephrine is the primary treatment to reverse the allergic reaction symptoms.

4. A nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

• A. "You can take this medication with a full glass of water."
• B. "You should store this medication in the refrigerator."
• C. "Take one tablet every 5 minutes until the pain is relieved, up to three doses."
• D. "You should avoid eating foods high in sodium while taking this medication."

Correct answer: C

Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.

5. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?

• A. Frothy, pink sputum
• B. Jugular vein distention
• C. Weight gain
• D. Bradypnea

Correct answer: A

Rationale: Correct! Frothy, pink sputum is a classic sign of pulmonary congestion in left-sided heart failure. This occurs due to the accumulation of fluid in the lungs, leading to the coughing up of frothy, pink-tinged sputum. Jugular vein distention (choice B) is more indicative of right-sided heart failure, where fluid backs up into the systemic circulation. Weight gain (choice C) may occur due to fluid retention, but it is not a direct manifestation of pulmonary congestion. Bradypnea (choice D) refers to abnormally slow breathing and is not specifically associated with pulmonary congestion.

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