Nursing Elites

1. A client is returning home after arthroscopy of the shoulder. The nurse should tell the client:

• A. To resume full activity the next day
• B. Not to eat or drink anything until the next morning
• C. To keep the shoulder completely immobilized for the rest of the day
• D. To report to the physician the development of fever or redness and heat at the site

Correct answer: D

Rationale: After arthroscopy, it is important for the client to report any signs of infection, such as the development of fever or redness and heat at the site, to the physician promptly. Options A, B, and C are incorrect. The client should not resume full activity the next day as rest and limited movement are usually recommended post-arthroscopy. It is not necessary to withhold food or fluids until the next morning; the client may resume the usual diet immediately unless otherwise instructed. While immobilization may be recommended for a period, keeping the shoulder completely immobilized for the rest of the day is not typically necessary post-arthroscopy.

2. The healthcare provider is assessing a client with chronic renal failure who is receiving hemodialysis. Which of the following findings would indicate a complication of the treatment?

• A. Temperature of 98.6°F (37°C).
• B. Weight gain of 2 lbs (0.9 kg) since the last treatment.
• C. Blood pressure of 130/80 mm Hg.
• D. Pulse rate of 72 bpm.

Correct answer: B

Rationale: Weight gain between dialysis sessions can indicate fluid overload, a common complication in clients with chronic renal failure. This can lead to complications such as hypertension, pulmonary edema, and heart failure. A normal temperature, blood pressure, and pulse rate are expected findings in this scenario and would not typically indicate a complication of hemodialysis treatment.

3. The nurse is providing teaching to a patient who will begin taking a cephalosporin to treat an infection. Which statement by the patient indicates a need for further teaching?

• A. I may stop taking the medication if my symptoms clear up.
• B. I should eat yogurt while taking this medication.
• C. I should stop taking the drug and call my provider if I develop a rash.
• D. I will not consume alcohol while taking this medication.

Correct answer: A

Rationale: Patients should take all of an antibiotic regimen even after symptoms clear to ensure complete treatment of the infection.

4. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?

• A. Cardiac arrhythmias.
• B. Hypertension.
• C. Seizures.
• D. Hypothermia.

Correct answer: A

Rationale: The correct answer is A: Cardiac arrhythmias. Reperfusion of cardiac tissue following t-PA administration can lead to cardiac arrhythmias, necessitating resuscitation equipment. Hypertension (choice B) is a common side effect of t-PA but is not directly related to reperfusion. Seizures (choice C) and hypothermia (choice D) are not typically associated with reperfusion from t-PA administration.

5. The nurse is preparing to begin a medication regimen for a patient who will receive intravenous ampicillin and gentamicin. Which is an important nursing action?

• A. Administer each antibiotic to infuse over 15 to 20 minutes.
• B. Order serum peak and trough levels of ampicillin.
• C. Prepare the schedule so that the drugs are given at the same time.
• D. Set up separate tubing sets for each drug labeled with the drug name and date.

Correct answer: D

Rationale: When administering intravenous aminoglycosides like gentamicin with penicillins such as ampicillin, it is crucial to avoid mixing them in the same container. Separate tubing sets labeled with the drug name and date should be used to prevent interactions between the medications. Administering each antibiotic over 15 to 20 minutes (Choice A) may not be appropriate for all medications and does not address the issue of compatibility. Ordering serum peak and trough levels of ampicillin (Choice B) is important for monitoring drug levels but does not directly address the administration process. Preparing a schedule to give drugs simultaneously (Choice C) may increase the risk of drug interactions and is not recommended when administering incompatible medications.

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