Nursing Elites

1. A nurse is planning care for a client who has a new prescription for metoprolol (Lopressor). Which assessment finding should the nurse report to the healthcare provider before administering the medication?

• A. Heart rate of 50 beats per minute
• B. Blood pressure of 90/60 mm Hg
• C. Respiratory rate of 20 breaths per minute
• D. Temperature of 99°F (37.2°C)

Correct answer: A

Rationale: A heart rate of 50 beats per minute is a concerning finding that should be reported before administering metoprolol. Metoprolol is a beta-blocker that can further lower the heart rate, so a heart rate of 50 bpm indicates potential bradycardia, which is a contraindication for administering this medication. Choices B, C, and D are within normal ranges and do not pose immediate concerns related to metoprolol administration.

2. The nurse is planning care for a 2-year-old child who is scheduled for an infusion of immune globulin for treatment of idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis has the highest priority for this child?

• A. Risk for infection
• B. Risk for injury
• C. Altered oral mucous membranes
• D. Risk for fluid volume deficit

Correct answer: A

Rationale: The correct answer is 'Risk for infection.' When caring for a child with ITP scheduled for immune globulin infusion, the highest priority is to prevent infection. This is crucial due to the risk of bleeding associated with ITP and the immunosuppression that can be caused by the condition and its treatment. The other options, such as 'Risk for injury,' 'Altered oral mucous membranes,' and 'Risk for fluid volume deficit,' are not as high a priority as preventing infection in this particular situation.

3. In attempting to develop a therapeutic relationship with a male adult client transferred to a psychiatric facility after being treated for a self-inflicted gunshot wound, which information is most important for the nurse to determine?

• A. The family's reaction to this situation
• B. The nurse's feelings about this client
• C. What losses the client recently experienced
• D. Why the client attempted to kill himself

Correct answer: C

Rationale: Understanding what losses the client recently experienced is crucial for the nurse in developing a therapeutic relationship. This information helps the nurse comprehend the client's emotional state, the potential triggers for the self-harm behavior, and provides insights into the client's current psychological and social challenges. Choice A, the family's reaction, may be important but is secondary to understanding the client's own experiences. Choice B, the nurse's feelings, is not relevant as the focus should be on the client. Choice D, why the client attempted suicide, is important but delving into recent losses can provide a broader context for the client's emotional distress and suicidal behavior.

4. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

• A. The depth of tissue destruction is minor
• B. Pain is interrupted due to nerve compression
• C. The full thickness burn has destroyed the nerves
• D. Second-degree burns are not usually painful

Correct answer: C

Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.

5. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?

• A. Dorsiflexes the right foot and left on command
• B. A 3 by 5 cm ecchymosis area covering the right calf
• C. Right calf is 3 cm larger in circumference than the left
• D. Bilateral lower extremity has 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.

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