Nursing Elites

1. During an initial assessment of a client, a nurse notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?

• A. Complete an incident report and place it in the client's medical record.
• B. Compare the current infusion with the prescription in the client's medication record.
• C. Contact the charge nurse to see if the prescription was changed.
• D. Submit a written warning for the nurse involved in the incident.

Correct answer: B

Rationale: The correct action for the nurse to take when noticing a discrepancy between the client's current IV infusion and the information received during the shift report is to compare the current infusion with the prescription in the client's medication record. This step is crucial to ensure the accuracy of the prescribed treatment and to prevent any potential harm to the client. Option A is incorrect because completing an incident report should only be done after verifying the discrepancy. Option C is incorrect as contacting the charge nurse should come after confirming the details. Option D is incorrect as submitting a written warning is not appropriate without verifying the information first.

2. What are the signs and symptoms of a pulmonary embolism?

• A. Sudden shortness of breath
• B. Chest pain
• C. Cough with blood
• D. All of the above

Correct answer: D

Rationale: A pulmonary embolism can manifest with sudden shortness of breath, chest pain, and coughing up blood. These symptoms are classic presentations of a pulmonary embolism due to the blockage of blood flow to the lungs. Therefore, the correct answer is 'All of the above.' Each symptom alone can be seen in various other conditions, but when occurring together, they strongly suggest a pulmonary embolism. Sudden shortness of breath is due to decreased oxygenation, chest pain can result from the strain on the heart, and coughing with blood may indicate damage to the lung tissue. Choosing any single symptom would not encompass the full range of presentations seen in a pulmonary embolism.

3. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the healthcare provider?

• A. Paradoxical excitement
• B. Headache
• C. Slowing of reflexes
• D. Fatigue

Correct answer: A

Rationale: The correct answer is A, paradoxical excitement. Lorazepam can cause an unexpected response of paradoxical excitement, which should be reported to the healthcare provider. This reaction is characterized by increased anxiety, restlessness, and agitation instead of the expected calming effect. Choices B, C, and D are incorrect because headache, slowing of reflexes, and fatigue are more common side effects of lorazepam and may not warrant immediate reporting unless severe or persistent.

4. What are the nursing priorities for a patient experiencing an asthma exacerbation?

• A. Administer a bronchodilator
• B. Encourage deep breathing
• C. Provide oxygen therapy
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.

5. A nurse is reinforcing teaching about cane use for a client with left-leg weakness. What should the nurse instruct the client to do?

• A. Use the cane on the weak side
• B. Maintain two points of support on the ground at all times
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: B

Rationale: The correct answer is B: Maintain two points of support on the ground at all times. When using a cane for left-leg weakness, the client should hold the cane in the right hand and advance the cane and the weak leg simultaneously. This technique provides the necessary support and stability. Option A is incorrect because the cane should be used on the side opposite the weakness to provide support. Option C is incorrect as advancing the cane too far with each step may cause the client to lose balance. Option D is incorrect because advancing the cane and the strong leg simultaneously does not provide the needed support for the weakened leg.

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