Nursing Elites

1. A patient with chronic pain is prescribed gabapentin. What is the primary purpose of this medication?

• A. Relieve neuropathic pain
• B. Reduce inflammation
• C. Enhance opioid analgesia
• D. Suppress cough

Correct answer: A

Rationale: Gabapentin is primarily prescribed to relieve neuropathic pain. It works by stabilizing electrical activity in the nerves, making it effective in managing conditions such as diabetic neuropathy, postherpetic neuralgia, and other forms of chronic pain originating from nerve damage.

2. After performing a paracentesis on a client with ascites, 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?

• A. Pedal pulses.
• B. Breath sounds.
• C. Gag reflex.
• D. Vital signs.

Correct answer: D

Rationale: Following a paracentesis where a significant amount of fluid is removed, it is crucial to monitor the client's vital signs. This helps in detecting any signs of hypovolemia, such as changes in blood pressure, heart rate, and respiratory rate, which could indicate complications post-procedure. Monitoring the vital signs allows for prompt intervention if there are any deviations from the baseline values.

3. The healthcare provider is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?

• A. Weigh the child daily.
• B. Observe the lower extremities for pitting edema.
• C. Measure the child's abdominal girth weekly.
• D. Weigh the child's wet diapers.

Correct answer: A

Rationale: Daily weighing is the most accurate method to monitor fluid retention in a child with nephrotic syndrome. Changes in weight can indicate fluid retention or loss, which is crucial in managing nephrotic syndrome. Observing for pitting edema and measuring abdominal girth are also important assessments, but daily weighing provides more immediate and precise information about fluid status.

4. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which finding should the nurse report to the healthcare provider immediately?

• A. Weight gain.
• B. Dry mouth.
• C. Muscle rigidity.
• D. Drowsiness.

Correct answer: C

Rationale: Muscle rigidity is a crucial finding to report immediately as it can indicate neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction to antipsychotic medications. NMS is characterized by muscle rigidity, high fever, autonomic dysfunction, and altered mental status. Prompt recognition and intervention are essential to prevent serious complications or death.

5. A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding requires immediate intervention?

• A. Fruity breath odor.
• B. Blood glucose of 450 mg/dL.
• C. Deep, rapid respirations.
• D. Serum potassium of 5.2 mEq/L.

Correct answer: C

Rationale: The correct answer is C: Deep, rapid respirations (Kussmaul breathing). This is a sign of severe acidosis commonly seen in diabetic ketoacidosis (DKA) and requires immediate intervention. Kussmaul breathing helps to compensate for the metabolic acidosis by blowing off carbon dioxide. Prompt intervention is necessary to prevent further deterioration and potential respiratory failure. Fruity breath odor (Choice A) is a classic sign of DKA but does not require immediate intervention. While a blood glucose level of 450 mg/dL (Choice B) is high, it does not pose an immediate threat to the client's life. Serum potassium of 5.2 mEq/L (Choice D) is slightly elevated but not the most critical finding that requires immediate intervention in this scenario.

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