Nursing Elites

1. A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?

• A. Administer antiemetics to reduce nausea.
• B. Obtain a list of the client's cardiac medications.
• C. Perform an ECG to evaluate heart function.
• D. Review the client's dietary intake for possible causes.

Correct answer: B

Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.

2. The nurse identifies an electrolyte imbalance, a weight gain of 4.4 lbs in 24 hours, and an elevated central venous pressure for a client with full-thickness burns. Which intervention should the nurse implement?

• A. Administer diuretics
• B. Review urine output
• C. Auscultate for irregular heart rate
• D. Increase oral fluid intake

Correct answer: C

Rationale: An elevated CVP and sudden weight gain indicate fluid overload, which can strain the heart. Auscultating for an irregular heart rate is crucial as electrolyte imbalances and fluid shifts after burns can lead to cardiac complications. Monitoring the heart rate is a priority to detect any cardiac distress early. While reviewing urine output and administering diuretics are important interventions, they should come after ensuring the client's cardiac status is stable. Increasing oral fluid intake may exacerbate the fluid overload, making it an inappropriate intervention in this scenario.

3. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?

• A. Had a cold and ear infection for the past two days
• B. Missed a dose of insulin
• C. Did not follow dietary restrictions
• D. Overexerted during exercise

Correct answer: A

Rationale: The correct answer is A. Infections, like a cold and ear infection, increase the body's metabolic needs and insulin resistance, making diabetic ketoacidosis (DKA) more likely. While missing insulin doses or not following dietary restrictions can trigger DKA, an illness is the most common precipitating factor in pediatric Type 1 diabetes. Option B is less likely as missing insulin can lead to hyperglycemia but might not be the immediate cause of ketoacidosis. Option C can contribute to DKA over time, but the acute trigger is usually an illness. Option D, overexertion during exercise, is less likely to cause DKA compared to an infection.

4. The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?

• A. Discontinue the medication immediately
• B. Increase the dose of haloperidol
• C. Complete the abnormal involuntary movement scale (AIMS)
• D. Monitor the client for signs of agitation

Correct answer: C

Rationale: These symptoms are characteristic of tardive dyskinesia, a side effect of long-term antipsychotic use. The nurse should assess the severity of these movements using the AIMS scale and report to the healthcare provider for further management. Discontinuing the medication abruptly (Choice A) can lead to withdrawal symptoms and worsening of the condition. Increasing the dose of haloperidol (Choice B) can exacerbate the symptoms of tardive dyskinesia. Monitoring for signs of agitation (Choice D) is important but does not address the specific side effect described.

5. What symptoms suggest the dosage of levothyroxine sodium is too high in a 26-year-old client with simple goiter?

• A. Bradycardia and constipation.
• B. Palpitations and shortness of breath.
• C. Lethargy and lack of appetite.
• D. Muscle cramps and dry skin.

Correct answer: B

Rationale: The correct answer is B: Palpitations and shortness of breath. These symptoms suggest excessive thyroid hormone levels, indicating that the levothyroxine dose is too high. Bradycardia and constipation (choice A) are more indicative of hypothyroidism, which occurs when thyroid hormone levels are low. Lethargy and lack of appetite (choice C) are also common symptoms of hypothyroidism. Muscle cramps and dry skin (choice D) can be associated with various conditions but are not specific to a high dosage of levothyroxine.

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