Nursing Elites

1. A patient took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the patient?

• A. Naloxone
• B. Acetylcysteine
• C. Flumazenil
• D. Activated charcoal

Correct answer: B

Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It works by replenishing glutathione, a key component in detoxifying acetaminophen metabolites, thus preventing liver damage. Naloxone is used to reverse opioid overdose, not acetaminophen. Flumazenil is a benzodiazepine antidote. Activated charcoal is used to limit absorption in cases of poisoning, but it is not the antidote for acetaminophen overdose.

2. What are the nursing interventions for a patient with hypertension?

• A. Monitor blood pressure and educate the patient about lifestyle changes
• B. Administer antihypertensive medications and provide dietary education
• C. Provide regular monitoring of blood pressure and administer diuretics
• D. Provide regular blood glucose monitoring

Correct answer: A

Rationale: The correct nursing interventions for a patient with hypertension involve monitoring blood pressure and educating the patient about lifestyle changes. These interventions help in managing hypertension by keeping track of the patient's blood pressure readings and empowering them with knowledge to make lifestyle modifications such as adopting a healthy diet, regular exercise, stress management, and avoiding smoking and excessive alcohol consumption. Administering antihypertensive medications (choice B) is typically done by a healthcare provider rather than a nurse. While regular monitoring of blood pressure (choice C) is important, administering diuretics is a specific medical intervention that should be prescribed by a healthcare provider. Monitoring blood glucose (choice D) is more relevant for patients with diabetes rather than hypertension.

3. A client is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

• A. Supine with head elevated
• B. Lateral recumbent
• C. Prone with arms at sides
• D. Sitting with back rounded

Correct answer: B

Rationale: The correct position for a lumbar puncture is the lateral recumbent position. This position allows the spine to curve naturally, widening the spaces between the vertebrae, making it easier and safer to perform the procedure. Supine with head elevated (Choice A) would not provide the proper positioning for a lumbar puncture as it does not allow for proper access to the lumbar area. Prone with arms at sides (Choice C) would not be suitable as it would not facilitate the procedure. Sitting with back rounded (Choice D) is also incorrect as it does not allow for the proper alignment of the spine needed for a lumbar puncture.

4. A client receiving chemotherapy for cancer has developed stomatitis. Which of the following interventions should the nurse implement?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct intervention for a client with stomatitis, a common side effect of chemotherapy, is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the mouth. Providing lemon-glycerin swabs (choice A) can be too harsh and irritating to the mouth. Avoiding toothpaste (choice C) is not necessary unless it contains harsh ingredients that can further irritate the mouth. Instructing the client to use a mouthwash containing alcohol (choice D) is contraindicated as alcohol-containing mouthwashes can be too harsh and drying for clients with stomatitis.

5. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

• A. Change the appliance daily
• B. Clean the stoma once a day
• C. Avoid changing the appliance for a week
• D. Change the appliance twice each week

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

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