Nursing Elites

1. At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

• A. Administer half of the missed dose immediately
• B. Administer the missed dose as soon as possible
• C. Give the missed dose with the next scheduled dose
• D. Withhold the missed dose unless seizure activity occurs

Correct answer: B

Rationale: Administering the missed dose as soon as possible is crucial in this situation. Missing an anticonvulsant dose can lead to breakthrough seizures, which are harmful to the client. Administering the missed dose promptly helps maintain the therapeutic level of the medication and reduces the risk of seizure activity. Giving half the dose may not provide adequate protection against seizures. Delaying the dose until the next scheduled time increases the time the client is without the medication, potentially increasing the risk of seizures. Withholding the missed dose unless seizure activity occurs is not recommended, as prevention is key in managing anticonvulsant therapy.

2. What intervention should the PN implement when taking the rectal temperature of an adult client?

• A. Lubricate the tip of the thermometer with a water-based gel.
• B. Gently insert the thermometer 1 inch into the rectum.
• C. Hold the thermometer in place the entire time while taking the temperature.
• D. Place the client in the left lateral position.

Correct answer: C

Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.

3. While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on these observations, what documentation should the PN include?

• A. Impaired verbalization
• B. Depressed mood
• C. Flat affect
• D. Diminished LOC

Correct answer: C

Rationale: The correct answer is C: 'Flat affect.' Flat affect refers to a lack of emotional expression, which the PN observed in the client. This observation is significant as it can provide valuable information for the client's mental health assessment and subsequent care planning. Choice A, 'Impaired verbalization,' does not capture the lack of emotional expression seen in the client. Choice B, 'Depressed mood,' may not accurately reflect the observed behavior of the client. Choice D, 'Diminished LOC,' pertains to the level of consciousness, which was not indicated as being a concern in the scenario provided.

4. Patients are coming into the emergency room as a result of an apartment house fire. You are examining a patient who is in distress but has no visible burn marks. You suspect that she is suffering from inhalation burns. Which of the following signs would NOT be associated with inhalation burns?

• A. Singed nasal hairs
• B. Conjunctivitis
• C. Hoarseness
• D. Clear sputum

Correct answer: D

Rationale: Clear sputum would not be associated with inhalation burns. Inhalation burns typically present with symptoms like singed nasal hairs, conjunctivitis, hoarseness, and possibly soot in sputum due to smoke inhalation. Clear sputum suggests that there is no significant inflammation or injury to the respiratory tract, which is not consistent with the typical findings in inhalation burns. The other choices are associated with inhalation burns: singed nasal hairs can occur due to exposure to hot air or gases, conjunctivitis can result from irritating substances in smoke, and hoarseness can be due to airway irritation.

5. Rehabilitation after illness is classified under which level of healthcare?

• A. Primary
• B. Secondary
• C. Tertiary
• D. All three

Correct answer: C

Rationale: Rehabilitation after illness is classified as tertiary care. Tertiary care aims to help patients recover from illness, injuries, or disabilities, and restore their functionality. Primary care involves preventive measures and early disease detection, while secondary care focuses on diagnosis and treatment of specific conditions. Therefore, choices A, B, and D are incorrect as they do not specifically address the specialized nature of rehabilitation in healthcare.

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