Nursing Elites

1. The client is being discharged after a concussion. Which of the following symptoms should be reported?

• A. Difficulty waking up
• B. Headache (3/10 on the pain scale)
• C. Bruising on knees and elbows
• D. Achy feeling all over

Correct answer: A

Rationale: The correct answer is 'Difficulty waking up' because it indicates a change in consciousness, which is a concerning symptom following a concussion. Reporting this symptom is crucial as it may signify a more severe head injury. 'Headache (3/10 on the pain scale)' may be common after a concussion but is not as urgent as a change in consciousness. 'Bruising on knees and elbows' is likely unrelated to the concussion and not a priority for reporting. 'Achy feeling all over' is a vague symptom and not specific to a concerning change in the client's condition post-concussion.

2. When administering intravenous electrolyte solution, which of the following precautions should the nurse take?

• A. Infuse hypertonic solutions cautiously.
• B. Mix no more than 60 mEq of potassium per liter of fluid.
• C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
• D. Monitor the client's digitalis dosage for potential adjustments due to IV calcium administration.

Correct answer: C

Rationale: When administering intravenous electrolyte solutions, it is crucial to prevent infiltration of calcium to avoid tissue necrosis and sloughing. Hypertonic solutions should be infused cautiously (Choice A) to prevent adverse effects. The correct amount of potassium to be mixed in a liter of fluid is no more than 60 mEq, making Choice B incorrect. While monitoring the client's digitalis dosage for potential adjustments due to IV calcium administration is important, the statement suggesting an increased dosage is incorrect as IV calcium diminishes digitalis's action, making Choice D incorrect.

3. The client with peripheral vascular disease is reviewing self-care measures. Which of the following statements indicates proper self-care measures?

• A. "I like to soak my feet in the hot tub every day."?
• B. "I walk to the mailbox in my bare feet."?
• C. "I stopped smoking and only use chewing tobacco."?
• D. "I have my wife examine the soles of my feet each day."?

Correct answer: D

Rationale: The correct answer is, "I have my wife examine the soles of my feet each day."? Clients with peripheral vascular disease should examine their feet daily for any signs of redness, dryness, or cuts. If the client is unable to do this themselves due to decreased sensation in their feet, a caregiver or family member should assist. Soaking feet in a hot tub should be avoided as the client may not be able to sense if the water is too hot, potentially causing burns. Walking barefoot can lead to injuries, so wearing shoes or slippers is recommended to minimize trauma. While quitting smoking is a positive step, using chewing tobacco can still constrict blood vessels, adversely affecting circulation in the extremities.

4. A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?

• A. Memory loss and lack of appetite
• B. Confusion and fatigue
• C. Heightened reflexes
• D. Tinnitus and spasticity

Correct answer: B

Rationale: The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.

5. A child with newly diagnosed leukemia is receiving chemotherapy. Which would be included in his plan of care by the nurse?

• A. Place the child in a negative pressure isolation room
• B. Administer prophylactic IV antibiotics
• C. Avoid high protein food intake
• D. Teach family and visitors handwashing techniques

Correct answer: D

Rationale: The correct answer is to teach family and visitors handwashing techniques. Any client on chemotherapy should have good infection control measures in place, such as handwashing by all who they encounter. Placing the child in a negative pressure isolation room (Choice A) is not necessary unless specifically indicated for a certain condition. Administering prophylactic IV antibiotics (Choice B) may not be part of the standard care plan for a child with leukemia receiving chemotherapy. Avoiding high protein food intake (Choice C) is not directly related to infection control and may not be necessary unless there are specific dietary restrictions.

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