Nursing Elites

1. A male client who fell into the lake while fishing and was submerged for about 3 min was successfully resuscitated by his friends. He was brought to the Emergency Department for evaluation and was admitted for a 24-hour uneventful hospital stay. What follow-up instruction should the nurse give?

• A. Avoid smoke-filled environments
• B. Seek medical care promptly if a fever develops
• C. Increase oral fluids if a cough becomes productive
• D. Schedule frequent rest periods

Correct answer: B

Rationale: After being submerged in water, the client should be instructed to seek medical care promptly if a fever develops since complications may arise later. Choices A, C, and D are not directly related to the potential complications from submersion in water and are therefore incorrect. Avoiding smoke-filled environments, increasing oral fluids for a productive cough, and scheduling frequent rest periods are not the priority concerns in this scenario.

2. The client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action for the nurse to initiate?

• A. Encourage continued use of the 3-point crutch gait by the client
• B. Encourage the client to use a wheelchair for mobility
• C. Instruct the client in the use of a 4-point crutch gait
• D. Instruct the client in the use of a 2-point crutch gait

Correct answer: C

Rationale: In this scenario, the client needs to avoid weight-bearing on the left leg. A 4-point crutch gait involves using both crutches and both legs, making it more appropriate for weight-bearing restrictions. Encouraging the use of a 3-point gait (choice A) would not provide adequate support for the client's condition. While using a wheelchair (choice B) could be an option, instructing the client in a 4-point crutch gait would promote mobility while adhering to weight-bearing restrictions. A 2-point crutch gait (choice D) involves using both crutches and one leg, which is not suitable for avoiding weight-bearing on the left leg.

3. The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understands the instruction?

• A. Aspirates the newborn’s nares using a syringe
• B. Applies a dressing to the cord after the newborn’s bath
• C. Breastfeeds the infant every hour during the night
• D. Positions the infant supine in the crib to sleep

Correct answer: D

Rationale: Positioning the infant supine in the crib to sleep is the correct action that indicates the mother understands the instruction. This position is recommended to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice A is incorrect as it is not a routine or recommended practice to aspirate the newborn’s nares using a syringe without a specific medical indication. Choice B is incorrect because applying a dressing to the cord after the newborn's bath is not a standard care practice. Choice C is incorrect because breastfeeding every hour during the night is excessive and not a recommended feeding schedule for a newborn.

4. A client complains of paresthesia in the fingers and toes and experiences hand spasms when the blood pressure cuff is inflated. Which serum laboratory finding should the nurse expect to find when assessing the client?

• A. Elevated serum calcium
• B. Low serum magnesium
• C. Low serum calcium
• D. Elevated serum potassium

Correct answer: C

Rationale: The correct answer is C: Low serum calcium. Hand spasms and paresthesia are indicative of potential hypocalcemia, which is characterized by low serum calcium levels. Elevated serum calcium (Choice A) is not consistent with the symptoms described. Low serum magnesium (Choice B) and elevated serum potassium (Choice D) are not typically associated with hand spasms and paresthesia.

5. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication?

• A. Increased urinary clearance of the multiple medications has led to diuresis and lowered the blood pressure.
• B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness.
• C. The additive effect of multiple medications has caused the blood pressure to drop too low.
• D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.

Correct answer: C

Rationale: The correct answer is C. When a client experiences syncope due to a significant drop in blood pressure after receiving multiple antihypertensive medications, the additive effect of these medications can cause the blood pressure to drop excessively. This additive effect can lead to hypotension, which is why the nurse decided to hold the client's scheduled antihypertensive medication. Choices A, B, and D provide incorrect rationales. Choice A mentions diuresis, which is not directly related to the drop in blood pressure due to additive medication effects. Choice B refers to an antagonistic interaction reducing effectiveness, which is not applicable in this scenario. Choice D talks about a synergistic effect leading to drug toxicity, which is not the cause of the sudden drop in blood pressure observed in the client.

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