Nursing Elites

1. A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first?

• A. Gastric lavage
• B. Administer acetylcysteine (Mucomyst) orally
• C. Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
• D. Have the patient drink activated charcoal mixed with water

Correct answer: A

Rationale: Acetaminophen overdose is extremely toxic to the liver causing hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting, abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis occurs and may lead to death. Removing as much of the drug as possible is the first step in treatment for acetaminophen overdose, this is best done through gastric lavage. Gastric lavage (irrigation) and aspiration consist of flushing the stomach with fluids and then aspirating the fluid back out. This procedure is done in life-threatening cases such as acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion.

2. Which client is at highest risk for developing a pressure ulcer?

• A. 23 year-old in traction for fractured femur
• B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
• C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
• D. 30 year-old who is comatose following a ruptured aneurysm

Correct answer: C

Rationale: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

3. A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?

• A. Abdominal distention
• B. A bruit near the epigastric area
• C. 3 episodes of vomiting in the last hour
• D. Blood pressure of 160/90

Correct answer: B

Rationale: A bruit near the epigastric area may indicate the presence of an aortic aneurysm, which is a life-threatening condition requiring immediate medical attention. Abdominal distention, while concerning, may not be as urgent as a potential aneurysm. Vomiting episodes may suggest underlying issues but do not present an immediate life-threatening situation. A blood pressure of 160/90, though elevated, does not pose the same level of immediate threat as a potential aortic aneurysm.

4. Which of the following can cause coup-contrecoup injuries?

• A. Rotational forces
• B. Deformation forces
• C. Deceleration forces
• D. Acceleration forces

Correct answer: C

Rationale: Deceleration forces occur when the head is moving and abruptly comes to a stop, such as in a car crash. This sudden deceleration can cause the brain to hit against the skull, resulting in coup-contrecoup injuries. In a coup-contrecoup injury, the brain is damaged on opposite sides due to the initial impact and the rebound effect inside the skull. Rotational forces usually result in diffuse axonal injuries rather than coup-contrecoup injuries. Deformation forces can cause focal brain injuries but not coup-contrecoup injuries. Acceleration forces typically lead to diffuse brain injuries, not coup-contrecoup injuries. Therefore, the correct answer is deceleration forces.

5. Which response would best assist the chemically impaired client in dealing with issues of guilt?

• A. Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior.
• B. What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?
• C. Don't focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs.
• D. You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done.

Correct answer: B

Rationale: The correct response is, 'What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?' This response encourages the client to reflect on their actions, identify sources of guilt, and develop a plan to address and reduce these feelings constructively. Choice A is incorrect as it dismisses the client's guilt as typical, potentially invalidating their emotions. Choice C is incorrect as it suggests avoiding guilty feelings by turning to substance use, which is counterproductive. Choice D is incorrect as it focuses on the negative consequences of the client's actions without offering a constructive way to address and alleviate guilt.

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