Nursing Elites

1. A patient with a urinary catheter reports discomfort. What is the nurse's priority action?

• A. Ensure the catheter tubing is not kinked.
• B. Irrigate the catheter to relieve the discomfort.
• C. Change the catheter to a smaller size.
• D. Remove the catheter and replace it with a new one.

Correct answer: A

Rationale: The correct answer is to ensure the catheter tubing is not kinked. This is the priority action because a kinked tubing can obstruct urine flow, leading to discomfort and potential complications. It is essential to troubleshoot the current catheter first before considering other interventions. Irrigating the catheter (Choice B) may not address the underlying issue of kinking. Changing the catheter to a smaller size (Choice C) or removing and replacing it with a new one (Choice D) should only be considered if ensuring the tubing is unkinked does not resolve the discomfort.

2. A client with a new prescription for sumatriptan tablets to treat migraine headaches should report which of the following symptoms to the nurse?

• A. Chew the tablet well before swallowing
• B. Report swelling of the eyelids after dosage
• C. Repeat dose in 1 hour for unrelieved headache
• D. Take daily to prevent headaches

Correct answer: B

Rationale: The correct answer is B because swelling of the eyelids is a side effect of sumatriptan tablets that requires immediate reporting to the healthcare provider to prevent further complications. Choices A, C, and D are incorrect. Chewing the tablet well before swallowing is not necessary for sumatriptan tablets. Repeating the dose in 1 hour for unrelieved headache is incorrect as this medication should not be repeated within 24 hours. Taking sumatriptan daily for headache prevention is also incorrect as it is used for acute treatment, not prevention.

3. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?

• A. Immediately do a complete head-to-toe neurological assessment.
• B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
• C. Place a blanket over the feet.
• D. Remove the restraint.

Correct answer: D

Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.

4. The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?

• A. Prepare for potential posttraumatic stress related to this bioterrorism attack.
• B. Transport patients quickly and efficiently through the elevators.
• C. Monitor for specific symptoms related to the bioterrorism attack.
• D. Manage all patients using standard precautions.

Correct answer: D

Rationale: During a potential bioterrorism attack, the priority for the nurse is to manage all patients using standard precautions. This approach ensures the safety of both patients and healthcare providers by preventing the spread of potential bioterrorism-related illnesses. Option A is incorrect because managing patient care and safety through standard precautions takes precedence. Option B is incorrect as patient transport should also be done while adhering to infection control measures. Option C is incorrect as monitoring for specific symptoms is important but not the priority when all patients need to be managed with standard precautions.

5. A nurse in the PACU is caring for a client who has received general anesthesia and has a manifestation of malignant hyperthermia. The nurse should expect to administer which of the following medications?

• A. Acetaminophen
• B. Ibuprofen
• C. Dantrolene
• D. Diazepam

Correct answer: C

Rationale: Corrected Rationale: Dantrolene is the medication of choice to treat malignant hyperthermia, a life-threatening reaction to general anesthesia. It works by inhibiting the release of calcium ions in skeletal muscle cells, preventing muscle contracture and hypermetabolism. Acetaminophen (Choice A) and ibuprofen (Choice B) are not indicated for treating malignant hyperthermia. Diazepam (Choice D) may be used to control muscle spasms but is not the first-line treatment for malignant hyperthermia.

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