Nursing Elites

1. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Watery diarrhea
• B. Nausea
• C. Headache
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention. Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.

2. Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated, and his blood pressure drops to 60/40. Which intervention should the nurse implement?

• A. Administer a second dose of nitroglycerin.
• B. Infuse a rapid IV normal saline bolus.
• C. Begin external chest compressions.
• D. Give a PRN antiemetic medication.

Correct answer: B

Rationale: In this scenario, the client's symptoms of nausea and a significant drop in blood pressure suggest a potential right ventricular infarction. The appropriate intervention for this situation is to infuse a rapid IV normal saline bolus. This fluid resuscitation helps improve cardiac output by increasing preload, which can be beneficial in right ventricular infarction. Administering a second dose of nitroglycerin may further lower blood pressure. External chest compressions are not indicated in this case as the client has a pulse. Providing an antiemetic medication does not address the underlying issue of hypotension and potential right ventricular involvement.

3. A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?

• A. Widening pulse pressure
• B. Sudden drop in heart rate
• C. A decrease in urine output
• D. Elevated blood pressure and widening pulse pressure

Correct answer: D

Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.

4. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

• A. Send stool specimen to the lab
• B. Measure abdominal girth
• C. Encourage increased fiber in the diet
• D. Monitor mental status

Correct answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.

5. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?

• A. Wheat products
• B. Foods sweetened with aspartame
• C. High-fat foods
• D. High-calorie foods

Correct answer: B

Rationale: The correct answer is B: Foods sweetened with aspartame. Aspartame should not be consumed by a child with PKU because it is converted to phenylalanine in the body, which can be harmful to individuals with PKU. Choice A (Wheat products) is not specifically contraindicated for PKU. Choice C (High-fat foods) and Choice D (High-calorie foods) are not typically restricted in PKU diets unless they contain high levels of phenylalanine.

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