Nursing Elites

1. Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?

• A. I am having pain in my lower back when I move my legs
• B. My throat hurts when I swallow
• C. I feel sick to my stomach and am going to throw up
• D. I have a headache that gets worse when I sit up

Correct answer: D

Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.

2. A client with a history of chronic heart failure is admitted with shortness of breath. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Chest X-ray
• B. Arterial blood gases (ABGs)
• C. Echocardiogram
• D. Electrocardiogram (ECG)

Correct answer: C

Rationale: The correct answer is an echocardiogram. This diagnostic test is crucial in assessing ventricular function and identifying the cause of shortness of breath in a client with heart failure. It provides valuable information about the heart's structure, function, and blood flow. While a chest X-ray may show signs of heart failure, it does not directly assess cardiac function like an echocardiogram does. Arterial blood gases (ABGs) are useful to evaluate oxygenation and acid-base balance but do not provide information specific to heart function. An electrocardiogram (ECG) assesses the heart's electrical activity and rhythm, which is important but may not provide the detailed structural information needed in this scenario.

3. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being... What intervention is most important for the nurse to implement?

• A. Teach the client about the use of a home pregnancy test.
• B. Schedule weekly home visits to draw hCG values.
• C. Schedule a 5-week follow-up with the healthcare provider.
• D. Begin chemotherapy administration during the first home visit.

Correct answer: B

Rationale: The most important intervention for the nurse to implement is to schedule weekly home visits to draw hCG values. Monitoring hCG levels is crucial in detecting potential complications like choriocarcinoma following GTD evacuation. Teaching about home pregnancy tests (Choice A) may not be as immediate and critical as monitoring hCG levels. A 5-week follow-up appointment (Choice C) may be too delayed for close monitoring. Initiating chemotherapy (Choice D) without appropriate hCG monitoring and evaluation is not recommended as the first-line intervention.

4. The mother of an adolescent tells the clinic nurse, 'My son has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.' What instruction should the nurse provide?

• A. Antibiotics take two weeks to become effective against fungal infections like athlete's foot.
• B. Continue using the ointment for a full week, even after the symptoms disappear.
• C. Applying too much ointment can reduce its effectiveness. Apply a thin layer to prevent maceration.
• D. Stop using the ointment and encourage complete drying of the feet and wearing clean socks.

Correct answer: D

Rationale: The correct answer is D. Athlete's foot (tinea pedis) is a fungal infection, not a bacterial infection that would respond to antibiotics. The primary management involves keeping the feet well-ventilated, dry after bathing, and wearing clean socks to prevent moisture buildup, which promotes fungal growth. Using an antibiotic ointment like triple antibiotic ointment is not effective for treating athlete's foot. Therefore, the nurse should advise the mother to stop using the antibiotic ointment and focus on promoting proper foot hygiene to manage the fungal infection. Choices A, B, and C are incorrect as they do not address the fungal nature of athlete's foot and the ineffectiveness of antibiotic ointments in its treatment.

5. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider immediately?

• A. Serum potassium of 5.5 mEq/L
• B. Serum calcium of 8 mg/dL
• C. Serum creatinine of 2.0 mg/dL
• D. White blood cell count of 10,000/mm³

Correct answer: A

Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to serious cardiac arrhythmias, especially during hemodialysis. Serum calcium, serum creatinine, and white blood cell count, while important, do not pose immediate life-threatening risks like hyperkalemia.

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