Nursing Elites

1. A client with urticaria due to environmental allergies is taking diphenhydramine. Which complaint should the nurse identify as a side effect of the OTC medication?

• A. Nausea and indigestion.
• B. Hypersalivation.
• C. Eyelid and facial twitching.
• D. Increased appetite.

Correct answer: A

Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. This medication can have anticholinergic effects, leading to these symptoms. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.

2. A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse take?

• A. Contact the healthcare provider immediately to report the laboratory value regardless of the advice.
• B. Document the finding and report it when the healthcare provider makes rounds.
• C. Notify the charge nurse that you are following the chain of command.
• D. Administer a potassium supplement and notify the provider later.

Correct answer: A

Rationale: A nurse should contact the healthcare provider immediately to report a critically low potassium level of 2 mEq/L. Potassium levels below the normal range can lead to life-threatening complications such as cardiac arrhythmias. Prompt notification is essential to ensure timely intervention and prevent harm to the patient. Option B is incorrect as delaying reporting such a critical value can jeopardize patient safety. Option C is not the priority in this situation; the focus should be on patient care. Option D is dangerous and inappropriate as administering a potassium supplement without healthcare provider's guidance can be harmful, especially with a critically low level.

3. A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?

• A. Initiate contact isolation.
• B. Obtain a wound swab for culture and sensitivity.
• C. Assess temperature every 4 hours.
• D. Use alcohol-based solutions for hand hygiene.

Correct answer: B

Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.

4. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L, and blood glucose is 310 mg/dl. Which action should the nurse implement?

• A. Infuse sodium chloride 0.9% (normal saline)
• B. Prepare an emergency dose of glucagon
• C. Determine the last time the client ate
• D. Check urine for ketone bodies with a dipstick

Correct answer: A

Rationale: In DKA, restoring fluid balance with sodium chloride is a priority to address the dehydration and electrolyte imbalances present in this condition. Choice B, preparing an emergency dose of glucagon, is incorrect because DKA is characterized by insulin deficiency, not glucagon deficiency. Choice C, determining the last time the client ate, is not the immediate priority in managing DKA. Choice D, checking urine for ketone bodies with a dipstick, may help confirm the diagnosis of DKA but is not the most critical intervention at this time.

5. Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?

• A. Distal pulse intensity
• B. Skin integrity
• C. Pain levels
• D. Range of motion

Correct answer: A

Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.

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