Nursing Elites

1. The nurse is preparing a discharge teaching plan for a liver transplant client. Which instruction is most important to include in this plan?

• A. Ensure daily follow-up with the healthcare provider
• B. Take immunosuppressant medications as prescribed
• C. Avoid crowds for the first two months after surgery
• D. Return to work in three months

Correct answer: B

Rationale: The most critical instruction to include in the discharge teaching plan for a liver transplant client is to take immunosuppressant medications as prescribed. This is vital to prevent organ rejection and ensure the success of the transplant. While ensuring daily follow-up with the healthcare provider is important for monitoring progress, avoiding crowds for the first two months after surgery helps reduce the risk of infections but is not as crucial as medication adherence. Returning to work in three months is a consideration but not the most important aspect immediately post-transplant.

2. Which intervention should the nurse include in the care plan for a child with tetanus?

• A. Ensure proper hydration
• B. Administer prescribed antibiotics
• C. Monitor vital signs frequently
• D. Minimize the amount of stimuli in the room

Correct answer: D

Rationale: The correct intervention for a child with tetanus is to minimize the amount of stimuli in the room. Tetanus causes severe muscle spasms and sensitivity to stimuli, so reducing stimuli like light, sound, and touch can help prevent painful spasms. While ensuring proper hydration and administering antibiotics are essential components of care, minimizing stimuli is crucial for the child's comfort and safety as it directly addresses the symptoms associated with tetanus.

3. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication dosage is too high?

• A. Increased sensitivity to cold.
• B. Increased heart rate and palpitations.
• C. Improved energy levels.
• D. Improved tolerance to heat.

Correct answer: B

Rationale: The correct answer is B: Increased heart rate and palpitations. When a client with hypothyroidism is prescribed levothyroxine, these symptoms may indicate that the dosage is too high, causing the client to develop hyperthyroidism. Choices A, C, and D are incorrect. Increased sensitivity to cold is a symptom of hypothyroidism, improved energy levels are an expected outcome of levothyroxine therapy for hypothyroidism, and improved tolerance to heat is not a common sign of levothyroxine overdose.

4. A client with a 42-week gestation refuses induction. What is the most important action the nurse should take?

• A. Discuss alternative ways to support the client's birth plan.
• B. Explain the risks of induction after 42 weeks.
• C. Ask the healthcare provider to discuss the situation with the client.
• D. Discuss the characteristics of labor with oxytocin vs. natural labor.

Correct answer: A

Rationale: The most important action for the nurse in this situation is to discuss alternative ways to support the client's birth plan. By doing so, the nurse can ensure that the client feels heard, respected, and supported in their decision-making process. While explaining the risks of induction after 42 weeks (Choice B) may be important, it is secondary to supporting the client's autonomy and preferences. Asking the healthcare provider to discuss the situation with the client (Choice C) may delay crucial communication and support that the nurse can provide. Discussing the characteristics of labor with oxytocin vs. natural labor (Choice D) is not the priority when the client has refused induction, as the focus should be on respecting their decision and exploring other options for support.

5. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

• A. Stop the transfusion and notify the healthcare provider.
• B. Administer an antihistamine as prescribed.
• C. Administer a dose of acetaminophen.
• D. Administer a PRN dose of diphenhydramine.

Correct answer: A

Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.

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