Nursing Elites

1. A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?

• A. Sore throat
• B. Vertigo
• C. Fever
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.

2. During a screening on a patient with a recent cast on the left lower extremity, which of the following statements should the nurse be most concerned about?

• A. The patient reports, "I didn't keep my extremity elevated as the doctor asked me to."?
• B. The patient reports, "I have been having pain in my left calf."?
• C. The patient reports, "My left leg has really been itching."?
• D. The patient reports, "The arthritis in my wrists is flaring up when I put weight on my crutches."?

Correct answer: B

Rationale: The correct answer is B because pain in the left calf could indicate a potential neurovascular complication related to the casted extremity. It could suggest issues such as compartment syndrome or impaired circulation. Option A is not as concerning since not elevating the extremity may lead to swelling but is not an immediate concern. Option C indicates itching, which is common with casts and not as concerning as potential neurovascular issues. Option D, regarding arthritis in the wrists, is unrelated to the lower extremity issue being screened for.

3. During the admission assessment for a client undergoing breast augmentation, which information should the nurse prioritize reporting to the surgeon before surgery?

• A. The client is concerned about who will care for her two children while she recovers.
• B. The client has a history of postoperative dehiscence after a previous C-section.
• C. The client's statement that her last menstrual period was 8 weeks prior.
• D. The client's concerns over pain control postoperatively.

Correct answer: C

Rationale: The most important information for the nurse to report to the surgeon before surgery is the client's statement that her last menstrual period was 8 weeks prior. This information is crucial as the client may be pregnant, and a pregnancy test will need to be completed before administering any anesthetic agents. Reporting this detail ensures patient safety and prevents potential risks associated with anesthesia. Choices A, B, and D are important aspects of care but do not take precedence over the need to rule out pregnancy before surgery.

4. Teaching about the need to avoid foods high in potassium is most important for which client?

• A. a client receiving diuretic therapy
• B. a client with an ileostomy
• C. a client with metabolic alkalosis
• D. a client with renal disease

Correct answer: D

Rationale: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. High potassium levels can further burden the kidneys and worsen the condition. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk for hypokalemia, which is low potassium levels. Therefore, these clients should actually be encouraged to eat foods high in potassium to maintain adequate levels and prevent complications associated with hypokalemia.

5. A nurse assesses an 83-year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage, and the patient has limited mobility in her home. Which of the following is the best course of action?

• A. Encourage warm water soaks to the right foot.
• B. Notify the case manager of the purulent drainage.
• C. Determine the patient's pulse in the right ankle.
• D. Recommend increased activity to reduce the purulent drainage.

Correct answer: A

Rationale: The correct course of action is to encourage warm water soaks to the right foot. This can help promote wound healing and alleviate discomfort. Before recommending increased activity or notifying additional team members, it is crucial to assess arterial blood flow by determining the patient's pulse in the right ankle. Poor arterial blood flow could worsen the condition, making increased activity inappropriate. While notifying the case manager of purulent drainage is important, addressing the wound care directly should be the primary focus at this stage.

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