Nursing Elites

1. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only
• B. Maintain intravenous fluid therapy per prescription
• C. Provide Pedialyte feedings via the nasogastric tube
• D. Offer the infant Pedialyte feedings every 2 hours

Correct answer: B

Rationale: Maintaining intravenous fluid therapy is crucial for managing dehydration and electrolyte imbalances caused by the vomiting in hypertrophic pyloric stenosis. Instructing the mother to give sugar water only (Choice A) is not appropriate as it does not address the dehydration and electrolyte imbalances adequately. Providing Pedialyte feedings via the nasogastric tube (Choice C) may not be sufficient to manage the severe fluid and electrolyte losses caused by the condition. Offering Pedialyte feedings every 2 hours (Choice D) may not be as effective as maintaining intravenous fluid therapy, especially in cases where rapid rehydration is necessary.

2. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

• A. Check the visual difficulties
• B. Note the most recent hemoglobin level
• C. Assess for hand and joint pain
• D. Observe rhythm on telemetry monitor

Correct answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

3. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?

• A. Take this medication with or without food
• B. Avoid using heat or ice on injured muscles while taking this medication
• C. Use cold and allergy medications only as directed by a healthcare provider
• D. Discontinue all nonsteroidal anti-inflammatory medications

Correct answer: C

Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.

4. The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?

• A. Measure the client's cardiac output
• B. Assess neurological status q15 min
• C. Collect a blood specimen for serum potassium
• D. Infuse lidocaine (Lidoject-1) at 20 to 50 mg/min

Correct answer: B

Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.

5. The nurse is providing discharge teaching to a client who has undergone abdominal surgery. What instruction should the nurse include?

• A. Avoid heavy lifting for at least 6 weeks
• B. Limit fluid intake to reduce the risk of infection
• C. Resume normal activities as soon as possible
• D. Avoid driving for at least 2 weeks

Correct answer: A

Rationale: The correct answer is A: 'Avoid heavy lifting for at least 6 weeks.' After abdominal surgery, it is essential to avoid heavy lifting to prevent complications such as incisional hernias and support proper healing. Choice B, 'Limit fluid intake to reduce the risk of infection,' is incorrect because adequate fluid intake is necessary for wound healing and preventing dehydration. Choice C, 'Resume normal activities as soon as possible,' is incorrect as it may increase the risk of complications and delay healing. Choice D, 'Avoid driving for at least 2 weeks,' is incorrect as the restriction on driving may vary depending on the type of surgery and individual recovery.

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