Nursing Elites

1. A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the perioperative nurse prepare to implement first?

• A. Ensure patency of an indwelling catheter and measure hourly intake and output.
• B. Prepare for cessation of the anesthesia and the surgical procedure.
• C. Obtain specimens of ABGs and serum electrolytes.
• D. Initiate cooling measures using iced normal saline by nasogastric lavage.

Correct answer: B

Rationale: The correct answer is B: Prepare for cessation of the anesthesia and the surgical procedure. Malignant hyperthermia is a severe reaction to certain medications used during general anesthesia. The immediate intervention to manage malignant hyperthermia is to stop the triggering agents, which include anesthesia and surgery. Ensuring patency of an indwelling catheter and measuring intake and output, obtaining specimens of ABGs and serum electrolytes, and initiating cooling measures are important interventions but should follow the immediate action of stopping the anesthesia and surgery to address the life-threatening condition of malignant hyperthermia.

2. Laboratory findings indicate that a client’s serum potassium level is 2.5 mEq/L. What action should the nurse take?

• A. Administer potassium supplements orally.
• B. Increase the client's dietary potassium intake.
• C. Inform the healthcare provider of the need for potassium replacement.
• D. Monitor the client's ECG continuously.

Correct answer: C

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.

3. A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?

• A. Elevated temperature
• B. Generalized weakness
• C. Diminished lung sounds
• D. Pain when swallowing

Correct answer: D

Rationale: In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.

4. The health care provider is treating a child with meningitis with a course of antibiotic therapy. When should the nurse expect the child to be out of isolation?

• A. When the course of antibiotics is complete
• B. When a negative CNS culture is obtained
• C. When the antibiotics have been initiated for 24 hours
• D. When the child has no symptoms of the disease

Correct answer: C

Rationale: The correct answer is C because a child with bacterial meningitis should be isolated for at least 24 hours until antibiotic therapy has been initiated. This period allows the antibiotics to start working against the infection, reducing the risk of spreading it to others. Choice A is incorrect because isolation is not solely based on completing the course of antibiotics; the initiation is crucial. Choice B is incorrect as waiting for a negative CNS culture may take longer and delay necessary precautions. Choice D is incorrect as symptom resolution does not guarantee the eradication of the infection and may still pose a risk of transmission.

5. After a CT scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?

• A. Call respiratory therapy to administer a breathing treatment.
• B. Send for an emergency tracheostomy set.
• C. Prepare a dose of epinephrine.
• D. Review the client's complete list of allergies.

Correct answer: C

Rationale: Preparing a dose of epinephrine is the correct intervention in this situation as the client is displaying symptoms of an anaphylactic reaction to the contrast medium used during the CT scan. Epinephrine is the first-line treatment for anaphylaxis due to its ability to reverse the symptoms rapidly. Calling respiratory therapy for a breathing treatment (Choice A) may not address the underlying allergic reaction and delay appropriate treatment. Sending for an emergency tracheostomy set (Choice B) is not indicated as the client's symptoms suggest an allergic reaction rather than airway obstruction. Reviewing the client's complete list of allergies (Choice D) is important but would not provide immediate relief for the client's current symptoms; administering epinephrine takes precedence in this situation.

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