Nursing Elites

1. After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse's next action be?

• A. Administer an anticoagulant.
• B. Warm the room and re-assess.
• C. Increase IV fluids.
• D. Notify the physician stat.

Correct answer: D

Rationale: The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (Choice A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (Choice B) may delay necessary treatment. Increasing IV fluids (Choice C) is unlikely to address the urgent vascular issue indicated by the symptoms described.

2. A 93-year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?

• A. Recommend the patient remain in her room at all times.
• B. Recommend family members bring pictures to the patient's room.
• C. Recommend a speech therapy consult to the doctor.
• D. Recommend the patient attempt to walk pushing the w/c for safety.

Correct answer: B

Rationale: For a 93-year-old female with Alzheimer's Disease exhibiting signs of increased confusion and limited stability with gait, recommending family members to bring pictures to the patient's room is the most appropriate course of action. Visual stimulation in the form of pictures may help decrease signs of confusion and provide comfort to the patient. Option A is incorrect as isolating the patient in her room at all times may worsen her condition by further limiting stimulation and interaction. Option C is incorrect as speech therapy may not directly address the current issues of confusion and gait instability. Option D is incorrect as pushing a wheelchair may not be safe for the patient if she is refusing to use it, potentially leading to falls or further distress.

3. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by:

• A. the inability of the kidneys to excrete the drug metabolites.
• B. rapid cell catabolism.
• C. toxic effects of the prophylactic antibiotics that are given concurrently.
• D. the altered blood pH from the acidic nature of the drugs.

Correct answer: B

Rationale: The correct answer is 'rapid cell catabolism.' During chemotherapy, rapid cell destruction occurs, leading to an increase in uric acid levels as a byproduct of cell breakdown. High uric acid levels are primarily a result of the rapid breakdown of cells during chemotherapy, not due to the kidneys' inability to excrete drug metabolites (Choice A). The prophylactic antibiotics given concurrently do not directly cause high uric acid levels (Choice C). The altered blood pH from the acidic nature of the drugs (Choice D) is not a direct cause of elevated uric acid levels; the main mechanism is the rapid cell catabolism that occurs during chemotherapy.

4. A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?

• A. Transferring the patient to the shower.
• B. Ambulating the patient for the first time.
• C. Taking the patient's breath sounds.
• D. Educating the patient on monitoring fatigue.

Correct answer: A

Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.

5. 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.

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