Nursing Elites

1. The patient has been in bed for several days and needs to be ambulated. What action should the nurse take first?

• A. Dangle the patient at the bedside.
• B. Encourage isometric exercises.
• C. Suggest a high-calcium diet.
• D. Maintain a narrow base of support.

Correct answer: A

Rationale: The correct answer is A: 'Dangle the patient at the bedside.' When a patient has been in bed for an extended period and needs to be ambulated, it is essential to dangle the patient at the bedside first. Dangling involves helping the patient sit on the edge of the bed with their legs over the side before standing up. This action helps prevent orthostatic hypotension, a sudden drop in blood pressure when moving from lying down to standing up, which can lead to dizziness or fainting. Encouraging isometric exercises (choice B) or suggesting a high-calcium diet (choice C) are not the first actions to take before ambulating a patient. Maintaining a narrow base of support (choice D) is related to assisting with ambulation but is not the initial step that should be taken.

2. A client is prescribed 1g of potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g in 250 ml of dextrose 5%. What rate should the nurse set the IV pump to run at?

• A. 40 ml/hr
• B. 42 ml/hr
• C. 44 ml/hr
• D. 46 ml/hr

Correct answer: B

Rationale: To calculate the IV rate, divide the total volume by the total time in hours. In this case, 1 g in 250 ml is to be infused over 6 hours. Therefore, 250 ml / 6 hr = 42 ml/hr. This means the IV pump should be set to run at 42 ml/hr. Choices A, C, and D are incorrect as they do not accurately calculate the infusion rate based on the provided information.

3. A healthcare provider is providing teaching for a patient with a prescription for oral metronidazole, what is the priority teaching point?

• A. Report headaches
• B. Report a rash
• C. Avoid sunlight
• D. Take with meals

Correct answer: B

Rationale: The correct answer is to 'Report a rash.' Metronidazole can cause severe adverse reactions like Stevens-Johnson syndrome, a life-threatening rash. It is crucial to educate the patient to report any rash immediately to prevent serious complications. Choices A, C, and D are incorrect because while they may be relevant to consider during metronidazole therapy, they are not the priority teaching point. Headaches can occur but are not as serious as a rash; avoiding sunlight is more related to doxycycline, not metronidazole; and taking with meals is a general instruction for some medications but not the priority teaching point for metronidazole.

4. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?

• A. Restrict the patient's fluid intake.
• B. Monitor the patient's daily weight.
• C. Administer diuretics as prescribed.
• D. Increase the patient's salt intake to promote fluid balance.

Correct answer: B

Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.

5. A nurse is assigned to care for a client with unstable blood pressure. What should the nurse do first?

• A. Monitor the client every two hours.
• B. Continuously monitor the client's vital signs.
• C. Wait for the healthcare provider to provide instructions.
• D. Ask the healthcare provider for specific instructions.

Correct answer: B

Rationale: In the case of a client with unstable blood pressure, the priority action for the nurse is to continuously monitor the client's vital signs. This allows for immediate detection of any fluctuations in blood pressure and timely intervention if necessary. Choice A, monitoring every two hours, may not provide real-time information needed for prompt intervention. Choices C and D suggest waiting for instructions from the healthcare provider, which could cause a delay in addressing the unstable blood pressure, potentially leading to adverse outcomes. Therefore, the most appropriate initial action is to continuously monitor the client's vital signs.

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