Nursing Elites

1. While assessing a client who is dying for signs of impending death, what should the nurse observe for?

• A. Elevated blood pressure
• B. Cheyne-Stokes respiration
• C. Elevated pulse rate
• D. Decreased temperature

Correct answer: B

Rationale: When assessing a client for signs of impending death, the nurse should observe for Cheyne-Stokes respiration. This pattern involves rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea. It is often associated with cardiac failure and can be a significant indicator of impending death. Elevated blood pressure and pulse rate are not typical signs of impending death; in fact, they may indicate other conditions. A decreased temperature is also not a common sign of impending death, as temperature changes can vary among individuals and may not always correlate with the dying process.

2. The client is being assessed for possible pernicious anemia. Which finding would support this diagnosis?

• A. A weight loss of 10 pounds in 2 weeks
• B. Complaints of numbness and tingling in the extremities
• C. A red, beefy tongue
• D. A hemoglobin level of 12.0 g/dL

Correct answer: C

Rationale: The correct answer is a red, beefy tongue, which is characteristic of pernicious anemia due to the atrophy of the papillae on the tongue. This finding is known as glossitis. A red, beefy tongue is a classic sign of pernicious anemia. Choice A, weight loss of 10 pounds in 2 weeks, is non-specific and not a typical finding in pernicious anemia. Choice B, complaints of numbness and tingling in the extremities, are more indicative of peripheral neuropathy, a common symptom of vitamin B12 deficiency, which can be seen in pernicious anemia. Choice D, a hemoglobin level of 12.0 g/dL, falls within the normal range and does not specifically point towards pernicious anemia, which is characterized by low hemoglobin levels due to impaired absorption of vitamin B12.

3. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?

• A. A client with brain attack (stroke) receiving tube feedings
• B. A client with congestive heart failure complaining of nighttime dyspnea
• C. A client who had a thoracotomy 6 months ago
• D. A client with Parkinson’s disease

Correct answer: B

Rationale: The correct answer is B. The client with congestive heart failure complaining of nighttime dyspnea should be seen first as airway management is a priority in nursing care. This client's symptoms indicate potential respiratory distress, requiring immediate attention. Choices A, C, and D involve clients who are more stable and do not present with urgent or acute conditions that require immediate intervention. Choice A with a client receiving tube feedings for a stroke may require attention, but the urgency of addressing potential respiratory distress in choice B takes precedence. Choice C, a client who had a thoracotomy 6 months ago, unless presenting with acute distress, does not necessitate immediate attention. Choice D, a client with Parkinson's disease, is usually a chronic condition that does not typically require immediate intervention for the described scenario.

4. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:

• A. administer both medications simultaneously.
• B. give the medications sequentially, and flush well between them.
• C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
• D. start one medication now and begin the other medication in 2-4 hours.

Correct answer: B

Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent interaction. Choice C is incorrect because the nurse, not the physician or pharmacy, should determine the correct administration sequence. Consulting with the pharmacist is appropriate if uncertain. Choice D is incorrect because delaying the second medication by several hours can slow the treatment of the client's infection, as both antibiotics are needed promptly to address the infection effectively. Therefore, the correct action is to give the medications sequentially and flush well between them to prevent any potential interactions.

5. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?

• A. Tinnitus
• B. Persistent cough
• C. Muscle weakness
• D. Diarrhea

Correct answer: B

Rationale: A persistent cough might be related to an adverse reaction to captopril (Capoten). Tinnitus (choice A) and diarrhea (choice D) are not commonly associated adverse reactions of captopril. Muscle weakness (choice C) might occur initially but is not considered a common adverse effect of captopril. Therefore, the correct answer is B, persistent cough, as it is a known adverse reaction to captopril.

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