Nursing Elites

1. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing may be potential evidence with legal implications.
• B. Such care facilitates the preservation of potential evidence.
• C. The clothing of a trauma victim can be used for further investigation.
• D. Such care maintains the integrity of the clothing for forensic analysis.

Correct answer: C

Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.

2. A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?

• A. Memory loss and lack of appetite
• B. Confusion and fatigue
• C. Heightened reflexes
• D. Tinnitus and spasticity

Correct answer: B

Rationale: The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.

3. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by:

• A. the inability of the kidneys to excrete the drug metabolites.
• B. rapid cell catabolism.
• C. toxic effects of the prophylactic antibiotics that are given concurrently.
• D. the altered blood pH from the acidic nature of the drugs.

Correct answer: B

Rationale: The correct answer is 'rapid cell catabolism.' During chemotherapy, rapid cell destruction occurs, leading to an increase in uric acid levels as a byproduct of cell breakdown. High uric acid levels are primarily a result of the rapid breakdown of cells during chemotherapy, not due to the kidneys' inability to excrete drug metabolites (Choice A). The prophylactic antibiotics given concurrently do not directly cause high uric acid levels (Choice C). The altered blood pH from the acidic nature of the drugs (Choice D) is not a direct cause of elevated uric acid levels; the main mechanism is the rapid cell catabolism that occurs during chemotherapy.

4. A central venous pressure reading of 11cm/H(2)O of an IV of normal saline is determined by the nurse caring for the patient. The patient has a diagnosis of pericarditis. Which of the following is the most applicable?

• A. The patient has a condition of hypovolemia.
• B. Not enough fluid has been given to the patient.
• C. Pericarditis may cause pressures greater than 10cm/H(2)O with testing of CVP.
• D. The patient may have a condition of arteriosclerosis.

Correct answer: C

Rationale: A central venous pressure reading above 10cm/H(2)O may indicate a condition of pericarditis, as the inflammation and fluid accumulation around the heart can lead to elevated pressures. Choices A, B, and D are incorrect. Hypovolemia would typically result in lower CVP readings, not higher. Not enough fluid given would also lead to lower CVP levels. Arteriosclerosis is not directly related to CVP readings in the context of pericarditis.

5. The client is being discharged after a concussion. Which of the following symptoms should be reported?

• A. Difficulty waking up
• B. Headache (3/10 on the pain scale)
• C. Bruising on knees and elbows
• D. Achy feeling all over

Correct answer: A

Rationale: The correct answer is 'Difficulty waking up' because it indicates a change in consciousness, which is a concerning symptom following a concussion. Reporting this symptom is crucial as it may signify a more severe head injury. 'Headache (3/10 on the pain scale)' may be common after a concussion but is not as urgent as a change in consciousness. 'Bruising on knees and elbows' is likely unrelated to the concussion and not a priority for reporting. 'Achy feeling all over' is a vague symptom and not specific to a concerning change in the client's condition post-concussion.

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