Nursing Elites

1. A healthcare provider is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider?

• A. Substernal retractions
• B. Hematuria
• C. Temperature 37.9�C (100.2�F)
• D. Sneezing

Correct answer: A

Rationale: Substernal retractions are a concerning sign of respiratory distress and can indicate acute chest syndrome, a severe complication of sickle-cell anemia. It results from vaso-occlusion in the pulmonary vasculature, leading to impaired oxygenation. Prompt reporting of this symptom is crucial for early intervention to prevent further complications. Hematuria, a high temperature, and sneezing are not specific manifestations of acute chest syndrome and would not warrant immediate notification to the provider in this context.

2. A client with heart failure has a new prescription for furosemide. Which of the following statements should the nurse make?

• A. Taking furosemide can cause your potassium levels to be high
• B. Eat foods that are high in sodium
• C. Rise slowly when getting out of bed
• D. Taking furosemide can cause you to be overhydrated

Correct answer: C

Rationale: Educating the client on the importance of rising slowly when getting out of bed is crucial due to the risk of orthostatic hypotension associated with furosemide use. This precaution helps prevent dizziness and falls. Options A and D are incorrect as furosemide commonly causes hypokalemia and dehydration, respectively, rather than high potassium levels or overhydration. Option B is inaccurate as clients on furosemide need to reduce sodium intake to manage fluid retention.

3. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?

• A. Use a professional interpreter service
• B. Nurse to interpret
• C. Provide translation services for a nominal fee to clients
• D. Evaluate the clients' understanding at regular intervals

Correct answer: B

Rationale: In situations where there is a language barrier between healthcare providers and patients, it is essential to ensure accurate communication. Using professional interpreter services is the most appropriate choice to ensure clear and precise communication. Relying on the client's children for interpretation may not guarantee accurate or confidential communication. Asking the nurse to interpret can lead to miscommunication or misunderstanding of important medical information. Providing translation services for a nominal fee to clients may not always be feasible or culturally appropriate. Regularly evaluating the client's understanding helps ensure that information is effectively communicated and comprehended.

4. Which of the following conditions may necessitate fluid restriction?

• A. Fever
• B. Chronic Obstructive Pulmonary Disease
• C. Renal Failure
• D. Dehydration

Correct answer: C

Rationale: Renal failure often necessitates fluid restriction to prevent fluid overload. In renal failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to fluid accumulation in the body. Restricting fluid intake helps manage this condition by preventing further fluid buildup and complications such as edema and electrolyte imbalances.

5. When preparing to administer eye drops to a school-age child, what actions should a nurse take?

• A. 52341
• B. 53241
• C. 35241
• D. 14325

Correct answer: A

Rationale: The correct sequence for administering eye drops to a school-age child is as follows: 5. Place the child in a sitting position, 2. Ask the child to look upward, 3. Pull the lower eyelid downward, 4. Instill the drops of medication, and 1. Apply pressure to the lacrimal punctum. Placing the child in a sitting position helps with stability and ease of access. Asking the child to look upward helps expose the conjunctival sac. Pulling the lower eyelid downward creates a pouch for instilling the drops. Instilling the drops of medication directly into the pouch ensures proper administration, and applying pressure to the lacrimal punctum prevents systemic absorption and promotes local action of the medication.

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