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 of the following is TRUE about shock?

• A. A patient with severe shock does not always have an abnormally low blood pressure.
• B. Confusion and deteriorating mentation are indicative of hypotensive shock.
• C. Patients with compensated shock may not be able to maintain a normal blood pressure.
• D. A normal blood pressure does not imply that the patient is stable.

Correct answer: B

Rationale: Confusion and deteriorating mentation are indeed indicative of hypotensive shock. It is important to note that a patient with hypotensive shock will likely exhibit deteriorating mental status. Choice A is incorrect because a patient in severe shock may not always have an abnormally low blood pressure, making it an unreliable indicator of shock severity. Choice C is incorrect because patients with compensated shock may present with normal blood pressure but still have inadequate tissue perfusion. Choice D is incorrect because a normal blood pressure does not guarantee the patient's stability, especially in cases of shock where tissue perfusion may be compromised despite normal blood pressure readings.

3. After hydrostatic reduction for intussusception, what client response should the nurse expect to observe?

• A. Abdominal distension
• B. Currant jelly-like stools
• C. Severe, colicky-type pain with vomiting
• D. Passage of barium or water-soluble contrast with stools

Correct answer: D

Rationale: After hydrostatic reduction for intussusception, the nurse should observe the passage of barium or water-soluble contrast with stools. This indicates a successful reduction of the telescoped bowel segment. Abdominal distension and currant jelly-like stools are clinical manifestations of intussusception, not expected outcomes following hydrostatic reduction. Severe, colicky-type pain with vomiting suggests an unresolved gastrointestinal issue, not a successful reduction of intussusception.

4. A 23-year-old woman is admitted to the infusion clinic after a Multiple Sclerosis exacerbation. The physician orders methylprednisolone infusions (Solu-Medrol). The nurse would expect which of the following outcomes after administration of this medication?

• A. A decrease in muscle spasticity and involuntary movements
• B. A slowed progression of Multiple Sclerosis-related plaques
• C. A decrease in the length of the exacerbation
• D. A stabilization of mood and sleep

Correct answer: C

Rationale: Methylprednisolone infusion is the first-line treatment during an acute exacerbation of Multiple Sclerosis. It is used to decrease the length and severity of a relapse by reducing inflammation in the central nervous system. Choice A, 'A decrease in muscle spasticity and involuntary movements,' is incorrect because methylprednisolone primarily targets inflammation and does not directly address muscle spasticity. Choice B, 'A slowed progression of Multiple Sclerosis-related plaques,' is incorrect as methylprednisolone is not used to slow the progression of the disease but rather to manage acute exacerbations. Choice D, 'A stabilization of mood and sleep,' is not an expected outcome of methylprednisolone administration for Multiple Sclerosis exacerbation as it primarily targets the inflammatory process associated with the relapse.

5. A client is undergoing radiation therapy for treatment of thyroid cancer. Following the radiation, the client develops xerostomia. Which of the following best describes this condition?

• A. Cracks in the corners of the mouth
• B. Peeling skin from the tongue and gums
• C. Increased dental caries
• D. Dry mouth

Correct answer: D

Rationale: Xerostomia, also known as dry mouth, is a common side effect of radiation therapy in the head and neck region. It occurs when the salivary glands are damaged during treatment, reducing saliva production and causing a dry sensation in the mouth. The correct answer is 'Dry mouth' (option D). Choice A, 'Cracks in the corners of the mouth,' describes angular cheilitis, a condition linked to nutritional deficiencies or candida infection. Choice B, 'Peeling skin from the tongue and gums,' is more indicative of conditions like oral thrush or mucositis. Choice C, 'Increased dental caries,' is a consequence of reduced saliva flow but does not specifically describe xerostomia.

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