Nursing Elites

1. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is MOST critical for the nurse to include in the plan of care?

• A. Hourly urine output
• B. White blood cell count
• C. Blood glucose every 4 hours
• D. Temperature every 2 hours

Correct answer: A

Rationale: Monitoring hourly urine output is crucial after successful resuscitation from a pulseless dysrhythmia to assess kidney function and perfusion. The kidneys are particularly vulnerable to injury following cardiac events due to decreased perfusion during the event. Evaluating urine output hourly allows for early detection of renal impairment or inadequate organ perfusion. Option B, monitoring white blood cell count, is not a priority in this situation as it does not directly relate to immediate post-resuscitation care. Option C, checking blood glucose every 4 hours, is important but not as critical as assessing kidney function and perfusion. Option D, measuring temperature every 2 hours, is relevant for monitoring signs of infection or inflammatory response but is not as crucial as assessing kidney function in this scenario.

2. A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the LPN/LVN monitor this client?

• A. Curling ulcer
• B. Renal shutdown
• C. Metabolic acidosis
• D. Hemolysis of red blood cells

Correct answer: C

Rationale: Corrected Rationale: Metabolic acidosis is a serious side effect of mafenide therapy that should be closely monitored. Mafenide can lead to metabolic acidosis due to its inhibition of carbonic anhydrase, resulting in the accumulation of carbonic acid. Curling ulcer (Choice A) is a stress-related mucosal lesion that occurs in the duodenum, primarily due to severe burns, not directly related to mafenide therapy. Renal shutdown (Choice B) is not a common side effect of mafenide therapy. Hemolysis of red blood cells (Choice D) is not a recognized side effect of mafenide cream application.

3. A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?

• A. Where the client ate his breakfast
• B. The times for routine vital sign measurements
• C. The exact times the client had visitors
• D. The type of transmission-based precautions in place

Correct answer: D

Rationale: Information about transmission-based precautions is essential for infection control and continuity of care.

4. Under the provisions of the Americans with Disabilities Act, what are nurse managers required to do?

• A. Maintain an environment free from associated hazards
• B. Provide reasonable accommodations for disabled individuals
• C. Make all necessary accommodations for disabled individuals
• D. Consider both mental and physical disabilities

Correct answer: B

Rationale: The correct answer is B: 'Provide reasonable accommodations for disabled individuals.' The Americans with Disabilities Act (ADA) mandates nurse managers to offer reasonable accommodations for disabled individuals to ensure equal opportunities in the workplace. Choice A is incorrect because although maintaining a hazard-free environment is essential, the focus of the ADA is on accommodations for disabled individuals. Choice C is incorrect as it overly generalizes the accommodations without specifying the need for them to be 'reasonable.' Choice D is incorrect because the ADA does not specify a requirement to consider both mental and physical disabilities; instead, it emphasizes providing reasonable accommodations regardless of the disability type.

5. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?

• A. Give the client information about immunization against meningitis.
• B. Tell the client to have a TB skin test every 2 years.
• C. Determine the client’s health risks.
• D. Teach the client about exercise recommendations.

Correct answer: C

Rationale: Assessing the client’s health risks is the priority as it provides essential information to guide subsequent care. By understanding the client’s health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.

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