Nursing Elites

1. A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care?

• A. Right lower abdominal pain
• B. Confusion
• C. Depression
• D. Peripheral neuropathy

Correct answer: B

Rationale: Confusion is a key symptom of Wernicke’s syndrome, which is due to thiamine deficiency. Wernicke’s syndrome is characterized by a triad of symptoms known as the classic triad, which includes confusion, ataxia, and ophthalmoplegia. Right lower abdominal pain, depression, and peripheral neuropathy are not typically associated with Wernicke’s syndrome, making them incorrect choices for this question.

2. A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only)

• A. 2
• B. 3
• C. 4
• D. 5

Correct answer: A

Rationale: To calculate the maximum dosage in mg that the nurse should administer, multiply the dose per administration (0.4 mg) by the maximum number of doses allowed (5 doses): 0.4 mg/dose * 5 doses = 2 mg. Therefore, the nurse should administer a maximum dosage of 2 mg to the client. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

3. While a patient is receiving beta-1b interferon every other day for multiple sclerosis, which serum laboratory test findings should the nurse monitor to assess for possible bone marrow suppression caused by the medication? (Select all that apply)

• A. Platelet count
• B. White blood cell count (WBC)
• C. Sodium and potassium
• D. Red blood cell count (RBC)

Correct answer: A

Rationale: Beta-1b interferon can lead to bone marrow suppression, impacting blood cell production. Therefore, monitoring the platelet count, white blood cell count (WBC), and red blood cell count (RBC) is essential. Platelet count is a direct indicator of bone marrow function and can show early signs of bone marrow suppression. While sodium, potassium, and albumin/protein levels are important for overall health assessment, they are not directly associated with bone marrow suppression caused by the medication.

4. A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?

• A. Cleanse the site around the catheter
• B. Use a 20 ml syringe to deflate balloon
• C. Clamp catheter until the client voids naturally
• D. Empty urine from the urinary drainage bag

Correct answer: B

Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.

5. The nurse is planning care for a family whose children did not receive childhood immunizations. After one of the children contracted mumps, the father is diagnosed with orchitis. Which intervention should be included in the father's plan of care?

• A. Use of bedrest with scrotal support
• B. Administration of antibiotics for 10 days
• C. Applying heat to promote the healing process
• D. Using an ice pack to reduce scrotal pain

Correct answer: A

Rationale: For orchitis, the recommended intervention is bedrest with scrotal support. This helps reduce swelling and discomfort in the scrotum. Antibiotics are generally not required for viral orchitis, so administering antibiotics for 10 days (Choice B) is not indicated. Applying heat (Choice C) may worsen swelling and should be avoided. Using an ice pack (Choice D) is not the preferred method for managing orchitis; it may not be as effective as providing support and rest for the scrotum.

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