Nursing Elites

1. A client with a history of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which complication should the nurse monitor for?

• A. Pulmonary embolism
• B. Gastrointestinal bleeding
• C. Hemorrhagic stroke
• D. Renal insufficiency

Correct answer: A

Rationale: The correct answer is A, pulmonary embolism. In a client with a history of deep vein thrombosis (DVT) receiving anticoagulant therapy, the nurse should monitor for pulmonary embolism, as it is a serious complication. Pulmonary embolism occurs when a blood clot dislodges from the veins and travels to the lungs, potentially causing life-threatening consequences. Choices B, gastrointestinal bleeding, C, hemorrhagic stroke, and D, renal insufficiency, are not directly associated with deep vein thrombosis or anticoagulant therapy. While these complications may occur in other situations, they are not the primary concern when managing a client with a history of DVT.

2. A client with a history of chronic alcoholism presents to the emergency department with a complaint of double vision. Which cranial nerve is most likely involved?

• A. Cranial nerve I (Olfactory)
• B. Cranial nerve III (Oculomotor)
• C. Cranial nerve VI (Abducens)
• D. Cranial nerve VII (Facial)

Correct answer: C

Rationale: The correct answer is Cranial nerve VI (Abducens). Chronic alcoholism can lead to damage to the abducens nerve, which controls the lateral movement of the eye. This damage can result in symptoms like double vision. Cranial nerve I (Olfactory) is responsible for the sense of smell and is not related to eye movement. Cranial nerve III (Oculomotor) controls most of the eye movements but is less likely to be affected in chronic alcoholism than the abducens nerve. Cranial nerve VII (Facial) is responsible for facial movements and is not associated with double vision.

3. When preparing to administer parenteral acyclovir (Zovirax) to an 80-year-old patient with chronic renal failure and herpes simplex, what would the nurse expect in regard to the dose?

• A. The dose is smaller due to the herpes simplex infection.
• B. The dose is smaller based on the patient's kidney function.
• C. The dose is higher in treating genital herpes.
• D. The dose is higher if the creatinine clearance is above 4.0 mg/dL.

Correct answer: B

Rationale: In patients with chronic renal failure, especially in older adults, dosages of medications excreted renally need to be adjusted based on kidney function. Acyclovir is primarily eliminated by the kidneys, so in a patient with chronic renal failure, the dose would need to be smaller to prevent drug accumulation and toxicity. Choice A is incorrect because the dose adjustment is more related to the patient's kidney function than the presence of herpes simplex. Choice C is incorrect because the type of herpes infection does not determine the dose adjustment for acyclovir. Choice D is incorrect as the creatinine clearance is a more accurate measure of kidney function compared to creatinine levels.

4. A client with cystic fibrosis is admitted with a pulmonary exacerbation. Which intervention should the nurse prioritize?

• A. Administer a high-calorie, high-protein diet.
• B. Initiate airway clearance techniques.
• C. Encourage the client to maintain an active lifestyle.
• D. Monitor for signs of respiratory distress.

Correct answer: B

Rationale: During a pulmonary exacerbation in cystic fibrosis, the priority intervention is to initiate airway clearance techniques. These techniques help clear mucus from the airways, improving ventilation and reducing the risk of respiratory complications. Administering a high-calorie, high-protein diet is beneficial for overall nutrition but is not the priority during an exacerbation. Encouraging an active lifestyle is important for long-term health but does not address the immediate need for managing exacerbations. Monitoring for signs of respiratory distress is important, but initiating airway clearance techniques takes precedence in the management of pulmonary exacerbations in cystic fibrosis.

5. In the ICU setting, a client transported from surgery following open heart bypass grafting will likely have his or her core temperature measured by:

• A. oral thermometer.
• B. rectal thermometer.
• C. esophageal thermometer.
• D. temporal artery thermometer.

Correct answer: C

Rationale: An esophageal thermometer is commonly used in ICU settings to accurately measure core body temperature, especially in post-surgical patients. The esophageal thermometer provides a more precise measurement of core temperature compared to other methods like oral, rectal, or temporal artery thermometers. In the ICU, accuracy in temperature measurement is crucial for detecting and responding to changes promptly, making the esophageal thermometer the preferred choice in this scenario.

Similar Questions