Nursing Elites

1. A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?

• A. Memory loss and lack of appetite
• B. Confusion and fatigue
• C. Heightened reflexes
• D. Tinnitus and spasticity

Correct answer: B

Rationale: The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.

2. What are the major electrolytes in the extracellular fluid?

• A. potassium and chloride
• B. potassium and phosphate
• C. sodium and chloride
• D. sodium and phosphate

Correct answer: C

Rationale: The correct answer is sodium and chloride. These two electrolytes are the major components of extracellular fluid. Potassium and phosphate (Choice B) are not the major electrolytes in the extracellular fluid. Potassium is primarily an intracellular ion, and phosphate is more abundant in the intracellular fluid and bones. Sodium and phosphate (Choice D) are also not the major electrolytes in the extracellular fluid. Chloride plays a crucial role in maintaining electrolyte balance and is predominantly found in extracellular fluid alongside sodium.

3. The client is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do?

• A. Allow the client to honestly discuss her fears and encourage her to talk more with her physician.
• B. Tell her the good things that she will be able to do without more children and encourage her to make a list of positive things.
• C. Explain to the client that her ovaries can be frozen for egg harvesting at a later time and she can find a surrogate.
• D. Advise the client to put off having the surgery until she is sure that she wants to undergo the procedure and notify the surgeon of the decision.

Correct answer: A

Rationale: In this situation, the most appropriate action for the nurse is to allow the client to express her fears and concerns openly. By encouraging her to talk more with her physician, the nurse is promoting effective communication and ensuring that the client receives adequate information to make an informed decision. Option A is correct because it acknowledges the client's emotions and empowers her to seek clarification and support from her healthcare provider. Options B and C do not address the client's emotional needs or provide a solution to her concerns regarding fertility. Option D is not appropriate as it does not prioritize the client's emotional well-being and delays necessary medical treatment for advanced cervical cancer.

4. The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?

• A. 15 seconds
• B. 3 minutes
• C. 5 minutes
• D. 15 minutes

Correct answer: B

Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.

5. A 14-year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse's first response be?

• A. Create an atmosphere of seclusion for the boy according to procedures.
• B. Remove other patients from the area for added safety.
• C. Ask the patient, "What is making you mad?"?
• D. Ask the patient, "Why are you behaving this way? Have you thought about what may help you calm down?"?

Correct answer: A

Rationale: In a situation where a patient is agitated and yelling, the first response should be to create an atmosphere of seclusion for the safety of the patient and others. Seclusion is a standard procedure to help manage aggressive behaviors and prevent harm. Options B, C, and D are not appropriate in this scenario. Removing other patients may not address the immediate safety concern, asking the patient what is making them mad can escalate the situation, and questioning why the patient is behaving that way may not help in managing the current agitation. Therefore, seclusion is the recommended course of action in this scenario to ensure the safety and well-being of all involved.

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