Nursing Elites

1. Because of the possible nervous system side-effects that occur with isoniazid (Nydrazid) therapy, which supplementary nutritional agent would the nurse teach the client to take as a prophylaxis?

• A. Alpha tocopherol (vitamin E)
• B. Ascorbic acid (vitamin C)
• C. Calcitriol (vitamin D)
• D. Pyridoxine (vitamin B6)

Correct answer: D

Rationale: Pyridoxine is the correct choice in this scenario because it is used as a prophylaxis to prevent neuritis, a possible nervous system side-effect of isoniazid therapy. Neuritis is a condition that involves inflammation of the nerves and can be a side effect of isoniazid. Pyridoxine, also known as vitamin B6, helps prevent this side effect. Vitamin E (Alpha tocopherol), vitamin C (Ascorbic acid), and vitamin D (Calcitriol) do not specifically address the nervous system side-effects associated with isoniazid therapy, making them incorrect choices.

2. A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?

• A. Administer Loritab to the patient for pain relief.
• B. Place the patient in a right sidelying position for pressure relief.
• C. Start a Central Line.
• D. Provide pain reduction techniques without administering medication.

Correct answer: D

Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.

3. A patient has just been prescribed Minipress to control hypertension. The nurse should instruct the patient to be observant of the following:

• A. Dizziness and light-headed sensations
• B. Weight gain
• C. Sensory changes in the lower extremities
• D. Fatigue

Correct answer: A

Rationale: The correct answer is 'Dizziness and light-headed sensations.' Minipress, a medication used to control hypertension, can cause hypotension as a side effect. Dizziness and light-headed sensations are common symptoms of hypotension. Weight gain, sensory changes in the lower extremities, and fatigue are not typically associated with Minipress or hypertension management. Therefore, they are incorrect choices.

4. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?

• A. Reassure the patient that pain is normal following surgery.
• B. Administer prn Nifedipine and assess the client's response.
• C. Administer prn Meperidine HCL and assess the client's response.
• D. Recheck BP and pulse rate every 20 minutes for the next hour.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.

5. After an escharotomy of the forearm, what is the priority nursing assessment for the client who has returned to your unit?

• A. Infection
• B. Incision
• C. Pain
• D. Tissue perfusion

Correct answer: D

Rationale: The correct answer is "Tissue perfusion." After an escharotomy, the priority assessment is to ensure adequate tissue perfusion to the affected limb. Escharotomy is performed to relieve circulatory compromise by cutting through the eschar, so monitoring tissue perfusion is crucial to assess the effectiveness of the procedure and prevent complications. Assessing for infection is important but comes after ensuring adequate tissue perfusion. Checking the incision is necessary but assessing tissue perfusion takes precedence. Pain assessment is important but not the priority compared to assessing tissue perfusion to prevent ischemic complications.

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