Nursing Elites

1. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?

• A. Urine output of 100 mL/hour.
• B. Intracranial pressure (ICP) of 20 mm Hg.
• C. Respiratory rate of 12 breaths/minute.
• D. Mean arterial pressure (MAP) of 70 mm Hg.

Correct answer: B

Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.

2. A client with a history of gout is experiencing an acute attack. Which medication should the nurse expect the healthcare provider to prescribe?

• A. Aspirin.
• B. Allopurinol (Zyloprim).
• C. Colchicine.
• D. Probenecid (Benemid).

Correct answer: C

Rationale: During an acute gout attack, the healthcare provider is likely to prescribe colchicine. Colchicine is commonly used to treat acute gout attacks because it works by reducing inflammation and alleviating pain associated with the condition. It is important to note that aspirin is not recommended for gout treatment and may even exacerbate the symptoms. Allopurinol and probenecid are medications used for long-term management of gout by reducing uric acid levels in the blood, but they are not typically prescribed during an acute attack. Therefore, colchicine is the most appropriate medication for managing an acute gout attack.

3. The client has undergone a thyroidectomy, and the nurse is providing care. Which assessment finding requires immediate intervention?

• A. Hoarseness and a sore throat.
• B. Difficulty swallowing.
• C. Numbness and tingling around the mouth.
• D. Temperature of 100.2°F (37.9°C).

Correct answer: C

Rationale: Numbness and tingling around the mouth can indicate hypocalcemia, a common complication post-thyroidectomy due to inadvertent parathyroid gland removal. Immediate intervention is required to prevent severe hypocalcemia manifestations like tetany or seizures. Hoarseness and a sore throat are common after a thyroidectomy due to surgical trauma and irritation to the vocal cords, not requiring immediate intervention. Difficulty swallowing can be expected due to postoperative swelling or edema, but it should be monitored closely. A temperature of 100.2°F is a mild fever and may be a normal postoperative response, not necessitating immediate intervention unless accompanied by other concerning symptoms.

4. A healthcare professional is educating a group of recent nursing graduates about their risks for contracting hepatitis B. What preventative measure should the professional promote?

• A. Immunization
• B. Chronic tonsillitis
• C. Consumption of a vitamin-rich diet
• D. Annual vitamin K injections

Correct answer: A

Rationale: The correct preventative measure to promote for preventing hepatitis B infection is immunization. Healthcare workers, including nurses, are at risk of exposure to hepatitis B, and vaccination is crucial in preventing infection. Immunization, along with adherence to standard precautions such as using personal protective equipment, proper hand hygiene, and safe needle practices, plays a vital role in protecting healthcare workers from contracting hepatitis B.

5. The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?

• A. Provide a high-calorie diet.
• B. Encourage frequent rest periods.
• C. Restrict fluid intake.
• D. Administer a stool softener.

Correct answer: B

Rationale: Encouraging frequent rest periods is essential in managing hyperthyroidism as it helps address the fatigue and hypermetabolic state commonly associated with this condition. Rest is crucial to support the body's recovery and reduce the stress on the thyroid gland. While nutrition is important in managing hyperthyroidism, providing a high-calorie diet is not the priority intervention. Restricting fluid intake is not typically necessary unless there are specific indications such as heart failure. Administering a stool softener is not directly related to managing hyperthyroidism.

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