Nursing Elites

1. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

• A. Fruit-flavored yogurt
• B. Cheese and crackers
• C. Cold cereal with skim milk
• D. Toasted wheat bread and jelly

Correct answer: D

Rationale: The correct answer is D: Toasted wheat bread and jelly. Dairy products decrease the effect of tetracycline, so the nurse should instruct the client to avoid them. Toast, which contains no dairy products, may help decrease gastrointestinal symptoms. Choices A, B, and C contain dairy products, which should be avoided when taking tetracycline.

2. The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which assessment finding is most concerning?

• A. Blood pressure of 110/70 mmHg
• B. Heart rate of 110 beats per minute
• C. Fever of 100.4°F
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A fever of 100.4°F is the most concerning assessment finding in a client with ESRD scheduled for hemodialysis. This elevation in temperature may indicate an underlying infection, which can lead to serious complications in individuals with compromised renal function. Prompt intervention is necessary to prevent the spread of infection and deterioration of the client's condition. The other vital signs mentioned, such as blood pressure, heart rate, and respiratory rate, while important to monitor, are within acceptable ranges and do not pose an immediate threat like a fever indicative of infection.

3. A male client with an antisocial personality disorder is admitted to an inpatient mental health unit for multiple substance dependencies. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client's history is most likely to include which finding?

• A. Multiple convictions for misdemeanors and class B felonies.
• B. A history of stable employment
• C. Strong relationships with family members
• D. A pattern of seeking help when needed

Correct answer: A

Rationale: The correct answer is A: Multiple convictions for misdemeanors and class B felonies. Clients with antisocial personality disorder often engage in behaviors that disregard societal rules and norms, leading to legal issues and criminal activities. This behavior is characteristic of individuals with antisocial personality disorder. Choices B, C, and D are incorrect because individuals with this disorder are less likely to have stable employment, strong family relationships, or seek help when needed due to their pattern of defiance and disregard for authority and rules.

4. The nurse is preparing to administer an intramuscular injection to a client with muscle wasting in the gluteal region. What is the most appropriate site for the injection?

• A. Dorsogluteal site
• B. Ventrogluteal site
• C. Deltoid site
• D. Vastus lateralis site

Correct answer: D

Rationale: The vastus lateralis site is the most appropriate for an IM injection in a client with muscle wasting in the gluteal region. Administering the injection in the vastus lateralis ensures effective medication delivery due to muscle wasting in the gluteal region, preventing potential complications associated with the dorsogluteal or ventrogluteal sites, which may not be suitable in this specific client case. The deltoid site is mainly used for smaller volumes of medication and may not be ideal for this scenario.

5. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow Coma Scale (GCS) every two hours. For the past 8 hours, the client's GCS score has been 14. What does this GCS finding indicate about the client?

• A. Neurologically stable without indications of increased ICP.
• B. At risk for neurological deterioration.
• C. Experiencing mild cognitive impairment.
• D. In need of immediate medical intervention.

Correct answer: A

Rationale: A GCS score of 14 indicates that the client is neurologically stable without indications of increased ICP. It suggests that the client's neurological status is relatively intact, with only mild impairment, if any. This finding reassures the nurse that there are currently no signs of deterioration or immediate need for intervention. Choice B is incorrect because a GCS score of 14 does not necessarily indicate immediate risk for neurological deterioration. Choice C is incorrect as mild cognitive impairment is not typically inferred from a GCS score of 14. Choice D is incorrect as immediate medical intervention is not warranted based on a GCS score of 14 without other concerning symptoms.

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