Nursing Elites

1. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select one that does not apply)?

• A. Administer hepatitis B vaccine.
• B. Test for antibodies to hepatitis B.
• C. Teach about alpha-interferon therapy.
• D. Give hepatitis B immune globulin.

Correct answer: C

Rationale: In the case of exposure to hepatitis B, the nurse should plan to administer hepatitis B vaccine to provide active immunity. Testing for antibodies to hepatitis B is essential to determine the individual's immune status. Giving hepatitis B immune globulin is necessary for passive immunity in cases of exposure. However, teaching about alpha-interferon therapy is not part of the standard management for hepatitis B exposure. Interferon therapy and oral antivirals are typically used in the treatment of chronic hepatitis B infections, not for prophylaxis after exposure.

2. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?

• A. Administer both drugs.
• B. Administer the spironolactone.
• C. Withhold the spironolactone and administer the furosemide.
• D. Withhold both drugs until discussed with the healthcare provider.

Correct answer: B

Rationale: A serum potassium level of 3.2 mEq/L is low (hypokalemia), which can be concerning in a patient with cirrhosis who is already at risk for electrolyte imbalances. Spironolactone is a potassium-sparing diuretic that can help increase the patient's potassium level and correct the hypokalemia. Therefore, the appropriate action for the nurse to take in this scenario is to administer the spironolactone. Withholding the spironolactone could further lower the potassium level. Furosemide, on the other hand, is a loop diuretic that can lead to potassium loss and worsen hypokalemia; hence, it should be withheld until the nurse discusses the situation with the healthcare provider. While the healthcare provider should be informed about the low potassium value, immediate administration of spironolactone is necessary to address the hypokalemia in this patient population.

3. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?

• A. INR is 3 seconds long
• B. Heart rate is 110 beats per minute
• C. Intracranial Pressure is 22 mmHg
• D. Blood pressure is 140/80

Correct answer: C

Rationale: The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.

4. The mother of a child who had a cleft palate repair 4 days ago is receiving home care instructions. Which statement by the mother indicates the need for further instruction?

• A. ''I will use a short nipple on the bottle.''
• B. ''I should avoid using straws for drinking.''
• C. ''I can give my child the pacifier in 2 weeks.''
• D. ''I may give my baby food mixed with water.''

Correct answer: B

Rationale: The correct answer is ''I should avoid using straws for drinking.'' After a cleft palate repair, the child should avoid straws, pacifiers, spoons, and fingers near the mouth for 7 to 10 days to prevent injury to the surgical site. Allowing the child to use a straw can create negative pressure in the mouth, potentially disrupting the healing process. The other options are appropriate postoperative instructions for a child who had a cleft palate repair and do not pose a risk to the surgical site.

5. A 33-year-old male client with heart failure has been taking furosemide for the past week. Which of the following assessment cues below may indicate the client is experiencing a negative side effect from the medication?

• A. Weight gain of 5 pounds
• B. Edema of the ankles
• C. Gastric irritability
• D. Decreased appetite

Correct answer: D

Rationale: The correct answer is 'Decreased appetite.' Furosemide is a loop diuretic used for conditions like heart failure, where it helps reduce fluid retention. One common side effect of furosemide is hypokalemia, which can lead to decreased appetite among other symptoms. Hypokalemia is a low level of potassium in the blood, and its signs and symptoms include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, and altered level of consciousness. Weight gain and ankle edema are actually expected outcomes of furosemide therapy due to its diuretic effect, which helps reduce edema and fluid overload. Gastric irritability is a nonspecific symptom that is not typically associated with furosemide use. Therefore, a decreased appetite is a key indicator of a potential negative side effect when assessing a client on furosemide therapy.

Similar Questions