Nursing Elites

1. When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?

• A. Ignore the behavior and administer the IV antibiotic
• B. Tell the client to stop the inappropriate behavior
• C. Leave the room and close the door quietly
• D. Complete an unusual occurrence report

Correct answer: C

Rationale: The correct action for the nurse in this situation is to leave the room and close the door quietly. This response respects the client's privacy, maintains professionalism, and avoids interrupting the client's personal moment. Choice A is incorrect because ignoring the behavior is not appropriate and may invade the client's privacy further. Choice B is incorrect as it can embarrass the client and the visitor, breaching their privacy and dignity. Choice D is also incorrect as the immediate priority is to respect the client's privacy and address the situation discreetly.

2. After receiving report, which client should the nurse assess last?

• A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
• B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
• C. An older client with a distended abdomen and no drainage from the nasogastric tube
• D. An adult client with rectal tube draining clear pale red liquid drainage

Correct answer: D

Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.

3. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide?

• A. Ensure to drink sugar-free cranberry juice
• B. Drinking cranberry juice does not prevent infection
• C. Cranberries do not affect insulin levels
• D. Excessive cranberry juice consumption can lead to constipation

Correct answer: B

Rationale: The correct answer is B: Drinking cranberry juice does not prevent urinary tract infections and should not be relied upon as a preventive measure. While cranberry juice is often associated with preventing UTIs, there is limited scientific evidence to support this claim. Choice A is incorrect because the sugar content in cranberry juice is not the main concern when discussing its role in preventing UTIs. Choice C is incorrect as there is no significant evidence to suggest cranberries affecting insulin levels. Choice D is incorrect as constipation is not a typical side effect of consuming cranberry juice; however, excessive consumption may lead to gastrointestinal discomfort.

4. What should the nurse monitor for during the IV infusion of vasopressin (Pitressin) in a client with bleeding esophageal varices?

• A. Vasodilatation of the extremities
• B. Chest pain and dysrhythmia
• C. Hypotension and tachycardia
• D. Decreasing GI cramping and nausea

Correct answer: B

Rationale: During the IV infusion of vasopressin in a client with bleeding esophageal varices, the nurse should monitor for chest pain and dysrhythmia. Vasopressin is a vasoconstrictor that can cause cardiovascular effects, including chest pain and dysrhythmias. Options A, C, and D are incorrect as vasopressin is not expected to cause vasodilatation of the extremities, hypotension, tachycardia, or improvements in GI symptoms such as cramping and nausea.

5. When assessing a client's blood pressure and determining an auscultatory gap, which action should the nurse implement?

• A. Compare the palpated systolic blood pressure with the auscultated pressure
• B. Assess the client for lightheadedness upon standing
• C. Determine if an automated blood pressure reading is consistent with the manual reading
• D. Observe for changes in blood pressure between lying and sitting positions

Correct answer: A

Rationale: When an auscultatory gap is present, comparing the palpated systolic blood pressure with the auscultated pressure is crucial. This helps to accurately measure blood pressure and detect any discrepancies caused by the gap. Assessing for lightheadedness upon standing (choice B) is unrelated to addressing an auscultatory gap. Checking the consistency between automated and manual blood pressure readings (choice C) is important for validation but not specifically for managing an auscultatory gap. Observing blood pressure changes between lying and sitting positions (choice D) is relevant for orthostatic hypotension assessment but not for dealing with an auscultatory gap.

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