Nursing Elites

1. Mr. V is receiving treatment for a spinal cord injury after falling off of his deck at home. He has undergone spinal surgery and has been placed in a halo traction device. Which of the following nursing interventions is most appropriate for a client with a spinal cord injury?

• A. Turn the client and use incentive spirometry each shift
• B. Administer stool softeners as ordered
• C. Turn the head slowly to avoid further damage to the spine
• D. Change NPO status

Correct answer: B

Rationale: In a client with a spinal cord injury, administering stool softeners as ordered is a crucial nursing intervention. Patients with spinal cord injuries are at higher risk of constipation due to decreased mobility. Stool softeners help prevent constipation and potential fecal impaction. Turning the client and using incentive spirometry each shift can be beneficial for respiratory function but is not the most vital intervention in this scenario. Turning the head slowly to avoid further damage to the spine is important but is not directly related to preventing constipation. Changing NPO status is not relevant to preventing constipation or managing a spinal cord injury.

2. A client was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?

• A. Whole grain cereal
• B. Eggs
• C. Cottage cheese
• D. Fish

Correct answer: A

Rationale: Diverticulosis is a condition characterized by small protrusions in the intestinal tract. To manage diverticulosis, a high-fiber diet is recommended. Foods rich in fiber help prevent constipation and reduce the risk of inflammation in the intestines. Whole grain cereals are an excellent source of fiber and can aid in maintaining bowel regularity. Eggs, cottage cheese, and fish are not high-fiber foods and may not provide the necessary dietary support for a client with diverticulosis. While protein-rich foods like eggs and fish are beneficial for overall health, they are not the primary recommendation for managing diverticulosis.

3. A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin?

• A. Diarrhea and Vomiting
• B. Dizziness and Drowsiness
• C. Metallic taste
• D. Hypoglycemia

Correct answer: D

Rationale: The correct answer is 'Hypoglycemia.' When a patient is on NPO status (nothing by mouth) and prescribed metformin, there is an increased risk of hypoglycemia due to the absence of oral intake. Metformin, as an anti-glycemic drug, can lower blood sugar levels, and without food intake, the risk of hypoglycemia is higher. Diarrhea and vomiting are common gastrointestinal side effects of metformin but are not the main concern in this scenario. Dizziness and drowsiness are potential side effects of some medications but are not typically associated with metformin. Metallic taste is a known side effect of metformin but is not the primary concern in this situation where hypoglycemia is more critical to monitor due to the patient's NPO status.

4. A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?

• A. The patient will be admitted to the medicine unit for observation and medication.
• B. The patient will be admitted to the day surgery unit for sclerotherapy.
• C. The patient will be admitted to the surgical unit and resection will be scheduled.
• D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.

Correct answer: C

Rationale: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.

5. Which of the following clients is most appropriate for receiving telemetry?

• A. A client with syncope potentially related to cardiac dysrhythmia
• B. A client with unstable angina
• C. A client with sinus rhythm and PVCs
• D. A client who had a myocardial infarction 6 hours ago

Correct answer: A

Rationale: Telemetry is used to monitor the cardiac rhythms of clients with potentially unstable conditions or those rhythms that affect activities. Clients with syncope potentially related to cardiac dysrhythmia require continuous monitoring to detect any potential life-threatening dysrhythmias. Unstable angina can be monitored in a telemetry unit, but syncope with potential cardiac causes takes precedence. Clients with sinus rhythm and PVCs may not necessitate telemetry unless there are further indications of instability. A client who had a myocardial infarction 6 hours ago is typically monitored in an intensive care unit rather than a telemetry unit.

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