Nursing Elites

1. A healthcare provider is reviewing the medical record of a client who has a new prescription for cimetidine. Which of the following laboratory findings should the healthcare provider identify as the priority to report to the provider?

• A. Sodium 140 mEq/L
• B. WBC count 9,000/mm3
• C. Aspartate aminotransferase (AST) 50 units/L
• D. Fasting glucose 105 mg/dL

Correct answer: C

Rationale: An elevated AST level is indicative of liver damage, which is the priority finding to report to the provider when administering cimetidine. Elevated liver enzymes can be a sign of liver toxicity or damage. Monitoring liver function is crucial when using cimetidine, as it can sometimes lead to hepatotoxicity. The other laboratory findings are within normal ranges and not directly associated with cimetidine administration.

2. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?

• A. The nursing student wears gloves when changing bed linens.
• B. The nursing student wears gloves to remove a wound dressing.
• C. The nursing student washes hands after removing gloves.
• D. The nursing student touches the patient's skin with sterile gloves.

Correct answer: D

Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.

3. A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?

• A. Urinary output
• B. Pain level
• C. Oxygen saturation
• D. Abdominal dressing

Correct answer: C

Rationale: The correct answer is C: Oxygen saturation. Following abdominal surgery, the priority assessment is to ensure adequate oxygenation. Monitoring oxygen saturation is crucial as the client may be at risk of respiratory complications due to the effects of anesthesia, pain medications, and the surgical procedure itself. Assessing urinary output is important for monitoring kidney function but is not the priority immediately postoperatively. Pain level assessment is essential for the client's comfort but does not take precedence over ensuring oxygen saturation. Checking the abdominal dressing is important for wound assessment, but ensuring adequate oxygenation is the priority in the immediate postoperative period.

4. What are the nursing priorities when caring for a patient with a newly placed peripherally inserted central catheter (PICC)?

• A. Performing sterile dressing changes
• B. Educating the patient on PICC line care
• C. Flushing the PICC line as prescribed
• D. Inspecting the insertion site for signs of infection

Correct answer: A

Rationale: The correct answer is A: Performing sterile dressing changes. When caring for a patient with a newly placed PICC line, one of the nursing priorities is to ensure proper care of the insertion site by performing sterile dressing changes. This helps prevent infections and maintain the integrity of the line. While educating the patient on PICC line care, flushing the PICC line as prescribed, and inspecting the insertion site for signs of infection are important aspects of care, the priority immediately after insertion is to maintain the sterility of the site through proper dressing changes.

5. A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?

• A. Administer an antiemetic to the client
• B. Notify housekeeping
• C. Prevent the client from aspirating
• D. Provide the client with an emesis basin

Correct answer: C

Rationale: Preventing aspiration is the priority when caring for a client who is vomiting to reduce the risk of pneumonia or other respiratory complications. Aspiration can occur when vomitus enters the airway, leading to respiratory distress. Ensuring the airway is protected during vomiting episodes is essential. Administering an antiemetic (Choice A) can be considered after addressing the immediate risk of aspiration. Notifying housekeeping (Choice B) and providing an emesis basin (Choice D) are important but are secondary to preventing aspiration, which is crucial for the client's safety and well-being.

Similar Questions