Nursing Elites

1. The client with peripheral artery disease has been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following?

• A. I should not be surprised if I bruise more easily or if my gums bleed a little when brushing my teeth.
• B. It is important to take this medicine with food to enhance its effectiveness and minimize stomach upset.
• C. I should stop taking Plavix if it makes me feel weak and dizzy.
• D. The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming.

Correct answer: C

Rationale: The correct answer is C. Weakness, dizziness, and headache are common adverse effects of Plavix and should be reported. It is essential to consult a physician before stopping Plavix as it plays a crucial role in preventing platelets from sticking together and forming clots. Choices A, B, and D are incorrect. Choice A is a common side effect of Plavix and does not indicate a need for further teaching. Choice B is incorrect because taking Plavix with or without food can affect its absorption and effectiveness. Choice D correctly explains the purpose of prescribing Plavix to prevent clot formation.

2. What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?

• A. Instruct the client to focus on a distant object behind the examiner and not move their eyes during the exam.
• B. Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
• C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
• D. For optimal visualization, keep the ophthalmoscope at least 3 inches from the client's eye.

Correct answer: C

Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.

3. A client with Diabetes Insipidus (DI) is being cared for by a nurse. Which data warrants the most immediate intervention by the nurse?

• A. Serum sodium of 185 mEq/L (185 mmol/L)
• B. Dry skin with poor skin turgor
• C. Apical rate of 110 beats per minute
• D. Polyuria and excessive thirst

Correct answer: A

Rationale: A serum sodium level of 185 mEq/L (185 mmol/L) is dangerously high and indicates severe dehydration, requiring immediate intervention to prevent neurological damage. The other options are not as critical as high serum sodium levels, which can lead to serious complications such as seizures, coma, and death if not promptly addressed. Dry skin with poor skin turgor and polyuria with excessive thirst are common findings in clients with Diabetes Insipidus and should be managed but do not pose an immediate threat to the client's life. An apical heart rate of 110 beats per minute may indicate tachycardia, which could be related to dehydration but is not as urgent as addressing the severe hypernatremia.

4. In a patient with pneumonia, what is the primary goal of treatment?

• A. Reducing inflammation.
• B. Eliminating the infection.
• C. Reducing pain.
• D. Preventing complications.

Correct answer: B

Rationale: The primary goal of treating pneumonia is to eliminate the infection. Antibiotics are commonly used to target the specific pathogen causing pneumonia. While reducing inflammation and preventing complications are important aspects of treatment, the key focus initially is on eradicating the infectious agent to improve the patient's condition and prevent further spread of the infection.

5. A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, the nurse should first assess:

• A. The client’s vital signs
• B. The amount of drainage
• C. The client’s lung sounds
• D. The chest tube connections

Correct answer: D

Rationale: The client’s dyspnea is most likely related to an air leak caused by a loose connection in the chest tube system. Checking the chest tube connections should be the initial action because correcting an air leak can quickly resolve the client's symptoms. If a leak is found and corrected, the dyspnea should improve. Assessing the client’s vital signs (Option A) is important, but addressing the potential cause of dyspnea takes precedence. Monitoring the amount of drainage (Option B) is necessary for assessing the client's overall condition, but in this case, the dyspnea is likely due to an air leak. Checking the client’s lung sounds (Option C) is essential for respiratory assessment, but addressing the air leak should be the immediate priority to ensure adequate lung expansion and oxygenation.

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