Nursing Elites

1. The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?

• A. Red man syndrome.
• B. Blood pressure of 130/80 mm Hg.
• C. Mild itching at the IV site.
• D. Nausea and vomiting.

Correct answer: A

Rationale: Red man syndrome is a severe and potentially life-threatening reaction to vancomycin characterized by flushing, rash, and hypotension. Immediate intervention is required to prevent further complications such as anaphylaxis. Therefore, the nurse should report this finding immediately to ensure prompt treatment and prevent serious adverse effects.

2. A healthcare provider is providing dietary teaching to a client with cholecystitis. Which type of diet should the healthcare provider recommend?

• A. High-fiber, low-fat diet
• B. Low-fiber, high-protein diet
• C. Low-fat, low-cholesterol diet
• D. High-protein, high-fat diet

Correct answer: C

Rationale: In cholecystitis, a low-fat, low-cholesterol diet is recommended to manage symptoms and reduce inflammation by reducing the workload on the gallbladder. This diet helps prevent gallbladder attacks and complications.

3. An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream. He reports a weak urine flow and frequent dribbling after voiding. Which nursing action should be implemented?

• A. Obtain a urine specimen for culture and sensitivity.
• B. Encourage the client to schedule a digital rectal exam.
• C. Advise the client to maintain a voiding diary for one week.
• D. Instruct the client in effective techniques for cleansing the glans penis.

Correct answer: B

Rationale: Encouraging the client to schedule a digital rectal exam is the most appropriate nursing action in this situation. This exam can help evaluate for potential prostate enlargement or other issues contributing to the urinary symptoms described by the client. It is important to assess the prostate gland for any abnormalities that may be causing the urinary issues reported by the client.

4. What is the most likely diagnosis in a 30-year-old woman with right upper quadrant pain, fever, and jaundice, along with elevated white blood cell count and bilirubin levels?

• A. Acute hepatitis
• B. Acute cholecystitis
• C. Acute cholangitis
• D. Pancreatic cancer

Correct answer: C

Rationale: The combination of right upper quadrant pain, fever, jaundice, elevated white blood cell count, and bilirubin levels is classic for acute cholangitis, which is an infection of the bile ducts. Acute hepatitis typically presents with other liver function abnormalities, while acute cholecystitis is characterized by gallbladder inflammation. Pancreatic cancer would not typically present with these specific symptoms and lab findings.

5. A client admitted with a diagnosis of sepsis has a central venous pressure (CVP) of 15 mm Hg. What should the nurse do first?

• A. Administer a fluid bolus of 500 ml.
• B. Notify the healthcare provider immediately.
• C. Administer a diuretic.
• D. Continue to monitor the CVP.

Correct answer: B

Rationale: A CVP of 15 mm Hg is higher than normal, indicating possible fluid overload or heart failure, which needs immediate attention. Notifying the healthcare provider is crucial as they can evaluate the client's condition, order appropriate interventions, and prevent potential complications.

Similar Questions