Nursing Elites

1. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis.
• B. Administer flumazenil to the client.
• C. Evaluate the client for further suicidal behavior.
• D. Initiate seizure precautions for the client.

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.

2. Which lab value is critical to monitor in patients receiving warfarin therapy?

• A. Monitor INR
• B. Monitor potassium levels
• C. Monitor platelet count
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial to monitor in patients receiving warfarin therapy. INR measures the blood's ability to clot and is used to ensure that patients are within the therapeutic range for warfarin therapy. This is important to prevent both clotting disorders and bleeding complications. Monitoring potassium levels (choice B) is not directly related to warfarin therapy. Platelet count (choice C) and sodium levels (choice D) are important parameters but are not as critical to monitor specifically for patients on warfarin therapy.

3. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of furosemide. Which of the following findings indicates the nurse should increase the client's infusion rate?

• A. Urine output of 20 mL/hr
• B. Heart rate of 90/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1 kg in 24 hr

Correct answer: D

Rationale: A weight gain of 1 kg in 24 hours can indicate fluid retention and worsening heart failure, requiring an increase in diuresis. This finding suggests that the current diuretic therapy is not effective enough to manage the fluid overload, necessitating an increase in the infusion rate of furosemide. Choices A, B, and C are not directly related to the need for an increase in diuretic therapy in heart failure patients. Urine output of 20 mL/hr, a heart rate of 90/min, and a sodium level of 138 mEq/L are important parameters to monitor but do not specifically indicate the need to increase the infusion rate of furosemide.

4. What is the priority intervention for a patient with a severe allergic reaction?

• A. Administer epinephrine
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions because it rapidly reverses the symptoms of anaphylaxis by constricting blood vessels, increasing heart rate, and relaxing airway muscles. Corticosteroids, although helpful to reduce inflammation, are not the priority in the acute management of severe allergic reactions. Oxygen may be needed to support breathing, but it is not the initial priority. Antihistamines are not as effective as epinephrine in treating severe allergic reactions and should not be the first intervention.

5. A client with gastroesophageal reflux disease (GERD) is being taught about dietary management by a nurse. Which of the following instructions should the nurse include?

• A. Avoid eating spicy foods.
• B. Eat three large meals each day.
• C. Lie down after meals.
• D. Increase your intake of dairy products.

Correct answer: A

Rationale: The correct instruction for a client with GERD is to avoid eating spicy foods. Spicy foods can trigger GERD symptoms by irritating the esophagus and increasing acid reflux. Choices B, C, and D are incorrect. Eating three large meals each day can exacerbate GERD symptoms by putting pressure on the lower esophageal sphincter, lying down after meals can worsen reflux due to gravity, and increasing dairy product intake may lead to higher fat consumption, which can also trigger GERD symptoms.

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