Nursing Elites

1. A nurse is providing discharge teaching to a client following a cholecystectomy. Which of the following instructions should the nurse include?

• A. I should avoid lifting objects heavier than 5 pounds for 1 week.
• B. I can resume my usual activities after 2 weeks.
• C. I should expect to have pain in my right shoulder.
• D. I should follow a low-protein diet for 1 week.

Correct answer: C

Rationale: The correct answer is C. Pain in the right shoulder after a cholecystectomy is common due to residual gas from the procedure. Choices A, B, and D are incorrect. It is important to avoid heavy lifting for a longer period than just 1 week to prevent complications. Resuming usual activities after 2 weeks may not be appropriate depending on the individual's recovery. Following a low-protein diet is not a standard recommendation post-cholecystectomy.

2. A nurse is preparing to administer vancomycin IV to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

• A. Administer the medication over 60 minutes
• B. Monitor the client's blood glucose level during administration
• C. Infuse the medication rapidly to reduce the risk of infection
• D. Administer the medication using a filter needle

Correct answer: A

Rationale: The correct action the nurse should take is to administer the medication over 60 minutes. This is important because administering vancomycin over 60 minutes helps prevent red man syndrome, a reaction that can occur with rapid infusion. Monitoring the client's blood glucose level (Choice B) is unrelated to vancomycin administration. Infusing the medication rapidly (Choice C) is incorrect and can lead to adverse reactions. Administering the medication using a filter needle (Choice D) is unnecessary for vancomycin administration.

3. A client is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Temperature of 37.1°C (98.8°F)
• C. Serosanguineous wound drainage
• D. Urine output of 25 mL/hr

Correct answer: D

Rationale: A urine output of 25 mL/hr is a sign of oliguria, which may indicate dehydration or kidney impairment and should be reported. A heart rate of 90/min is within the normal range (60-100/min) for adults at rest and may be expected postoperatively. A temperature of 37.1°C (98.8°F) is within the normal range (36.1-37.2°C or 97-99°F) and does not indicate an immediate concern. Serosanguineous wound drainage is a common finding postoperatively and indicates a normal healing process.

4. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has sinus arrhythmia and is receiving monitoring.
• B. A client who has a hip fracture and a new onset of tachypnea.
• C. A client who has epidural analgesia and weakness in the lower extremities.
• D. A client who has diabetes and a hemoglobin A1C of 6.8%.

Correct answer: B

Rationale: The correct answer is B because a new onset of tachypnea can indicate a respiratory complication, which requires immediate assessment. Sinus arrhythmia, epidural analgesia with weakness, and a hemoglobin A1C level of 6.8% in a client with diabetes do not pose immediate life-threatening concerns that require urgent assessment compared to the potential respiratory issues associated with tachypnea.

5. What is the best intervention for a patient with respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Administer corticosteroids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.

Similar Questions