Nursing Elites

1. What is the appropriate action when a patient experiences an allergic reaction to a medication?

• A. Administer epinephrine
• B. Discontinue the medication
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for a severe allergic reaction as it helps to constrict blood vessels, increase heart rate, and open airways, thereby improving breathing and circulation. Discontinuing the medication may not be sufficient to manage a severe allergic reaction as the allergen is already in the patient's system. Corticosteroids and antihistamines can be considered as complementary treatments but are not the primary immediate intervention required for a severe allergic reaction.

2. A client has a new prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication with food to prevent nausea.
• B. Notify your provider if you experience visual disturbances.
• C. Take an antacid with this medication if indigestion occurs.
• D. Avoid taking this medication if your heart rate is less than 60/min.

Correct answer: B

Rationale: The correct instruction for a client taking digoxin is to notify their provider if they experience visual disturbances. Visual disturbances can be a sign of digoxin toxicity, and prompt notification to the healthcare provider is essential for timely intervention. Choice A is incorrect because digoxin should be taken on an empty stomach for better absorption. Choice C is incorrect because antacids can interfere with the absorption of digoxin. Choice D is incorrect because a heart rate less than 60/min is not a sole reason to avoid taking digoxin; rather, it is important to monitor the heart rate and consult with the healthcare provider if there are concerns.

3. What is the priority intervention for a patient with dehydration?

• A. Administer IV fluids
• B. Monitor intake and output
• C. Administer oral fluids
• D. Provide electrolyte replacement

Correct answer: A

Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.

4. A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 91%
• B. Use of pursed-lip breathing
• C. Productive cough with green sputum
• D. Decreased breath sounds in the right lower lobe

Correct answer: D

Rationale: The correct finding the nurse should report to the provider is decreased breath sounds in the right lower lobe. This can indicate a respiratory infection or atelectasis in clients with COPD, requiring further evaluation and intervention. Choice A, an oxygen saturation of 91%, although slightly lower than normal, does not necessarily require immediate reporting unless the client's baseline is significantly higher. Choice B, the use of pursed-lip breathing, is actually a beneficial technique for clients with COPD to improve oxygenation and reduce shortness of breath, so it does not need reporting. Choice C, a productive cough with green sputum, can be common in clients with COPD and may indicate an infection, but it is not as concerning as decreased breath sounds in a specific lung lobe which may signify a more acute issue.

5. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

• A. Insert the catheter 7.5 cm (3 in) into the urethra.
• B. Insert the catheter until urine flow is established.
• C. Cleanse the catheter with sterile water before insertion.
• D. Insert the catheter 5 cm (2 in) into the urethra.

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

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