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. During an assessment, a healthcare professional suspects a client has cholecystitis. What is a common symptom of this condition?

• A. Right upper quadrant pain
• B. Left lower quadrant pain
• C. Generalized abdominal pain
• D. Epigastric pain

Correct answer: A

Rationale: Right upper quadrant pain is a hallmark symptom of cholecystitis, indicating inflammation of the gallbladder. The gallbladder is typically located in the right upper quadrant of the abdomen, so pain in this area is characteristic of cholecystitis. This pain may be sharp or cramp-like and can be accompanied by other symptoms such as nausea, vomiting, and fever. Left lower quadrant pain (choice B) is more commonly associated with diverticulitis, generalized abdominal pain (choice C) can be seen in various conditions, and epigastric pain (choice D) is typically related to issues in the upper central part of the abdomen, such as gastritis or peptic ulcers, rather than cholecystitis.

3. A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of the prescribed 4 mg. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states her pain has subsided. What is the legal status of the nurse?

• A. The nurse is guilty of negligence and will be sued.
• B. The client would not be able to prove malpractice in court.
• C. The nurse is protected by the Good Samaritan Act.
• D. The healthcare provider should have given the morphine sulfate dose.

Correct answer: B

Rationale: The correct answer is B because, in this scenario, the client would not be able to prove malpractice in court. Despite the nurse administering a higher dose of morphine than prescribed, the client's respiratory rate, oxygen saturation, and pain relief indicate that no harm resulted from the error. Therefore, the client would not have legal grounds to pursue a malpractice case against the nurse.

4. When creating a care plan for a 70-year-old obese client admitted to the postsurgical unit following a colon resection, the client's age and increased body mass index put them at increased risk for which complication in the postoperative period?

• A. Hyperglycemia
• B. Azotemia
• C. Falls
• D. Infection

Correct answer: D

Rationale: Infection is a significant risk in obese, elderly clients due to decreased immunity and increased healing time, making them more susceptible to postoperative infections. Proper infection prevention measures should be a priority in the care plan for this client to minimize this risk.

5. What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. International normalized ratio (INR)
• D. Platelet count

Correct answer: C

Rationale: The international normalized ratio (INR) is the appropriate parameter to monitor the effectiveness of enoxaparin in preventing clot formation in patients with deep vein thrombosis (DVT). INR reflects the clotting ability of the blood and is commonly used to assess the therapeutic range of anticoagulant medications, such as enoxaparin, which is crucial in managing and preventing thrombotic events like DVT.

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