Nursing Elites

1. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?

• A. Monitor gastrointestinal pain
• B. Ask the client about pain levels
• C. Check the client's vital signs
• D. Assess for signs of bleeding

Correct answer: B

Rationale: The correct answer is to ask the client about pain levels. Proton pump inhibitors (PPIs) work by reducing stomach acid to alleviate gastrointestinal pain. By inquiring about the client's pain experience, the nurse can directly assess the effectiveness of the medication. Monitoring bowel movements (Choice A) is not directly related to evaluating the effectiveness of a PPI. Checking vital signs (Choice C) may not reflect the medication's effectiveness in reducing stomach acid. Assessing for signs of bleeding (Choice D) is important but not the most direct way to evaluate the effectiveness of a PPI.

2. A client with atrial fibrillation is prescribed warfarin. Which instruction should the nurse include in the teaching?

• A. Maintain a consistent intake of leafy green vegetables
• B. Use an electric razor when shaving
• C. Monitor blood pressure daily
• D. Avoid eating bananas and oranges

Correct answer: B

Rationale: Clients on warfarin are at increased risk of bleeding due to its anticoagulant effects. Using an electric razor reduces the risk of cuts and bleeding, which is an important safety precaution. While leafy greens should not be avoided, their intake should be consistent to maintain a stable level of vitamin K in the body. Monitoring blood pressure daily is important for other conditions but not directly related to warfarin therapy. Avoiding bananas and oranges is not a standard instruction for clients on warfarin.

3. An older client with a long history of coronary artery disease, HTN, and HF arrives in the ED in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect in the client with acute HF?

• A. Decreased heart rate
• B. Improved blood pressure
• C. Increased urine output
• D. Reduced preload

Correct answer: D

Rationale: The correct answer is D: Reduced preload. Furosemide is a diuretic that reduces fluid overload in heart failure, which lowers the preload (the volume of blood in the ventricles before contraction). By reducing this volume, furosemide improves symptoms of heart failure. While furosemide may lead to increased urine output and lower blood pressure, these effects are secondary to the reduction in preload. Decreased heart rate is not a direct effect of furosemide in heart failure.

4. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.

5. The mother of a 2-day-old infant girl expresses concern about a 'flea bite' type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

• A. We need to monitor the rash for signs of worsening or fever
• B. Your baby may have an allergic reaction to laundry detergent
• C. This is a common newborn rash that will resolve after several days
• D. This is likely a bacterial infection requiring antibiotics

Correct answer: C

Rationale: The rash described is typical of erythema toxicum neonatorum, a common and benign newborn rash that resolves on its own within a few days. No treatment is necessary, and the nurse should reassure the mother. Choice A is incorrect as the rash is self-limiting and does not require monitoring for worsening signs or fever. Choice B is incorrect as erythema toxicum neonatorum is not caused by an allergic reaction to laundry detergent. Choice D is incorrect as this rash is not indicative of a bacterial infection that requires antibiotics.

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