Nursing Elites

1. An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor signs of increased bleeding
• B. Instruct on the use of incentive spirometry
• C. Observe for confusion and restlessness
• D. Administer intravenous opioids for severe pain

Correct answer: A

Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.

2. Which client requires careful nursing assessment for signs and symptoms of hypomagnesemia?

• A. A young adult client with intractable vomiting from food poisoning
• B. A client who developed hyperparathyroidism in late adolescence
• C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
• D. A female client who is overzealous with her intake of simple carbohydrates

Correct answer: A

Rationale: The correct answer is A. Vomiting can lead to significant loss of magnesium, causing hypomagnesemia. In this scenario, the young adult client with intractable vomiting from food poisoning is at higher risk of developing hypomagnesemia due to the loss of magnesium through vomiting. Choices B, C, and D are less likely to present with hypomagnesemia. Hyperparathyroidism (B) is associated with hypercalcemia, renal failure (C) can lead to hypermagnesemia, and overconsumption of simple carbohydrates (D) is not directly linked to magnesium imbalances.

3. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

4. A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client’s plan of care?

• A. High risk for infection related to subclavian catheter
• B. High risk of injury related to ambulation
• C. Knowledge deficit related to a high-protein diet
• D. Hygiene self-care deficit related to uremic frost

Correct answer: D

Rationale: The correct answer is D. Uremic frost is a condition in which urea and other waste products are excreted through the skin, leaving a powdery residue. This indicates poor hygiene and self-care, common issues in patients with CKD and renal osteodystrophy. Proper hygiene measures are essential to prevent complications. Choices A, B, and C are less likely to be included in the plan of care for a CKD patient with renal osteodystrophy. Choice A is more related to a vascular access issue, choice B is more related to mobility concerns, and choice C is more related to dietary education.

5. A male client with diabetes mellitus takes NPH/regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of azithromycin an hour before breakfast as instructed. What action should the nurse implement?

• A. Provide a PRN dose of an antacid to take with the azithromycin right after breakfast
• B. Offer to obtain a new breakfast tray in an hour so the client can take the azithromycin
• C. Instruct the client to eat his breakfast and take the azithromycin two hours after eating
• D. Tell the client to skip that day's dose and resume taking the azithromycin the next day

Correct answer: C

Rationale: Azithromycin should ideally be taken on an empty stomach; however, if taken after breakfast, it should not affect its efficacy. Instructing the client to eat his breakfast and take the azithromycin two hours after eating allows for proper absorption without compromising its effectiveness. Providing an antacid with azithromycin is not necessary in this case. Offering a new breakfast tray in an hour or skipping the dose is not the best course of action as it may lead to missed doses and potential effectiveness issues.

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