Nursing Elites

1. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Administer antihypertensive medication
• B. Notify the healthcare provider
• C. Recheck the blood pressure
• D. Document the blood pressure in the chart

Correct answer: C

Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.

2. A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?

• A. Inhale the medication for 1 second
• B. Shake the inhaler vigorously before use
• C. Hold the inhaler 1-2 inches from the mouth
• D. Exhale immediately after inhalation

Correct answer: C

Rationale: The correct instruction for a client using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance allows for the proper delivery of the medication into the lungs. Choice A is incorrect because the duration of inhalation can vary depending on the medication, and 1 second may not be adequate. Choice B is incorrect as shaking the inhaler vigorously is not necessary for all MDIs and can lead to inaccurate dosing. Choice D is incorrect as the client should hold their breath for about 10 seconds after inhalation to allow the medication to deposit in the lungs.

3. A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?

• A. Irrigate the catheter with normal saline
• B. Notify the provider
• C. Assess for signs of infection
• D. Administer prescribed antibiotics

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.

4. A nurse is assessing a client who has received intermittent enteral feedings. What finding indicates the client is tolerating the feeding?

• A. Nausea and vomiting
• B. Normal bowel sounds
• C. Weight gain
• D. Decreased abdominal distention

Correct answer: D

Rationale: The correct answer is D: Decreased abdominal distention. This finding indicates that the client is tolerating the feeding well without experiencing bloating or discomfort. Nausea and vomiting (choice A) are symptoms of intolerance to enteral feedings. Normal bowel sounds (choice B) are a good sign but do not directly indicate tolerance to the feeding. Weight gain (choice C) may occur due to factors other than enteral feedings.

5. A nurse is monitoring a client receiving intermittent enteral feedings. What should the nurse identify as a sign of intolerance to the feeding?

• A. Decreased heart rate
• B. Nausea
• C. Fever
• D. Weight gain

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.

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