Nursing Elites

1. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

• A. The client has asymmetrical chest wall expansion
• B. The client complains of pain at the insertion site
• C. The client's chest x-ray indicates decreased pleural effusion
• D. The client's arterial blood gases show pH 7.35, PaO2 85, PaCO2 35, HCO3 26

Correct answer: A

Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.

2. A client is admitted with pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?

• A. Tissue sloughing upon extravasation
• B. Elevated blood pressure and heart rate
• C. Tinnitus and vertigo
• D. Erythema of the face, neck, and chest

Correct answer: C

Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.

3. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbecue that afternoon. What question is most important for the triage nurse to ask this client?

• A. Have you recently traveled outside the United States?
• B. How high was your temperature when you returned home?
• C. Have you taken any medication to treat these symptoms?
• D. Is anyone else sick who was also at the picnic?

Correct answer: D

Rationale: The most important question for the triage nurse to ask the client in this scenario is whether anyone else who attended the picnic is also sick. This is crucial to identify a potential outbreak or common source of infection. Asking about recent travel may be important for infectious diseases but is not as relevant as identifying a common source among individuals who shared the same food. Inquiring about the client's temperature is important but does not provide immediate insight into the cause of symptoms. Asking about medication taken is relevant but not as critical as determining if others are affected, which could indicate a foodborne illness.

4. The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

• A. Low-grade fever
• B. Bruising of the skin
• C. Abdominal cramping
• D. Bloody emesis

Correct answer: D

Rationale: The correct answer is D: Bloody emesis. Bloody emesis indicates potential bleeding or severe irritation, which should be reported immediately. In the context of acute gastritis, bloody emesis could indicate a more serious complication that requires urgent medical attention. Choices A, B, and C are not typically associated with acute gastritis caused by contaminated water and do not signal as critical of a condition as bloody emesis. Low-grade fever, bruising of the skin, and abdominal cramping are more commonly associated with other conditions or may be less urgent in this context.

5. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?

• A. Administer antianxiety medication before providing discharge instructions
• B. Schedule a follow-up appointment for an outpatient psychosocial assessment
• C. Obtain a blood cortisol level before discharge
• D. Encourage the client to remain in the hospital for a few more days

Correct answer: B

Rationale: The correct intervention is to schedule a follow-up appointment for an outpatient psychosocial assessment. This option addresses the client's concerns and provides support for managing stress and preventing future crises, which is crucial for the client's long-term care. Administering antianxiety medication before providing discharge instructions (Choice A) may not effectively address the underlying concerns. Obtaining a blood cortisol level before discharge (Choice C) is important but not the priority in this situation. Encouraging the client to remain in the hospital for a few more days (Choice D) is not the best course of action as it may not address the client's anxiety and could potentially lead to other issues.

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