Nursing Elites

1. A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

• A. A cerebral vascular accident
• B. Postoperative meningitis
• C. Medication reaction
• D. Metabolic alkalosis

Correct answer: A

Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice C) is not the most probable cause given the history provided. Metabolic alkalosis (choice D) is not associated with sudden seizing in this context.

2. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?

• A. Oculogyric crisis
• B. Tardive dyskinesia
• C. Nystagmus
• D. Dysphagia

Correct answer: A

Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.

3. The healthcare provider calculates the IV flow rate for a patient receiving lactated Ringer's solution. The patient needs to receive 2000mL of Lactated Ringer's over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. How many drops per minute should the healthcare provider set the IV to deliver?

• A. 8
• B. 10
• C. 14
• D. 18

Correct answer: C

Rationale: To determine the drops per minute, we use the formula Drops Per Minute = (Milliliters x Drop Factor) / Time in Minutes. In this case, Drops Per Minute = (2000mL x 15 drops/mL) / (36 hours x 60 minutes/hour) = 30000 / 2160 = 13.89 (approximately 14). Therefore, the correct answer is 14 drops per minute. Choice A (8), Choice B (10), and Choice D (18) are incorrect as they do not correctly calculate the drops per minute based on the given information.

4. The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?

• A. A high WBC count and decreased level of consciousness
• B. A high WBC count and manic activity
• C. A low WBC count and manic activity
• D. A low WBC count and decreased level of consciousness

Correct answer: A

Rationale: The correct answer is 'A high WBC count and decreased level of consciousness.' Meningitis is often caused by an infectious organism, leading to an increase in Intracranial Pressure (ICP), which can result in decreased level of consciousness. While meningitis can trigger an inflammatory response, it typically presents with an elevated white blood cell (WBC) count rather than a low WBC count. Manic activity is not a common clinical manifestation of meningitis; instead, patients may exhibit altered mental status, confusion, or lethargy.

5. A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?

• A. Monitor for fever every 4 hours.
• B. Require visitors to wear respiratory masks and protective clothing.
• C. Consider transfusion of packed red blood cells.
• D. Check for signs of bleeding, including examination of urine and stool for blood.

Correct answer: D

Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (Choice A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (Choice B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (Choice C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.

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