Nursing Elites

1. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

• A. Nutrition
• B. Elimination
• C. Activity
• D. Safety

Correct answer: D

Rationale: In caring for a client with severe depression, safety is a critical priority. The nurse must address precautions to prevent suicide as part of the care plan. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the immediate risk of harm associated with depression. Ensuring the client's safety by implementing measures to prevent self-harm or suicide is the priority intervention. Addressing nutrition, elimination, and activity can follow once the client's safety is assured.

2. A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following?

• A. Observe for neurological changes
• B. Monitor for any signs of renal failure
• C. Check the food diary
• D. Observe for signs of bleeding

Correct answer: D

Rationale: The priority concern for a client receiving thrombolytic medication, such as tissue plasminogen activator (alteplase), is to monitor for signs of bleeding. Thrombolytics work by converting plasminogen to plasmin, which degrades fibrin. This process can lead to the breakdown of both fibrin-bound plasminogen on thrombi surfaces and unbound plasminogen in the plasma. The resulting plasmin can degrade fibrin, fibrinogen, factor V, and factor VIII. Observing for signs of bleeding is crucial due to the increased risk of hemorrhage associated with thrombolytic therapy. Monitoring for neurological changes, signs of renal failure, or checking the food diary are not the immediate priorities compared to detecting and managing potential bleeding complications.

3. What intervention should the nurse implement while a client is having a grand mal seizure?

• A. Open the jaw and place a bite block between the teeth
• B. Try to place the client on his side
• C. Restrain the client to prevent injury
• D. Place pillows around the client

Correct answer: B

Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.

4. A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6�F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?

• A. Codeine
• B. Guaifenesin (Robitussin)
• C. Acetaminophen (Tylenol)
• D. Piperacillin/tazobactam (Zosyn)

Correct answer: D

Rationale: The correct answer is Piperacillin/tazobactam (Zosyn). Early initiation of antibiotic therapy is crucial in cases of community-acquired pneumococcal pneumonia to reduce mortality. While providing symptomatic relief with medications like Codeine for cough, Guaifenesin for mucus clearance, and Acetaminophen for fever and pain is important, the priority should be to start antibiotic therapy to target the underlying infection. Piperacillin/tazobactam is an appropriate choice for treating severe community-acquired pneumonia caused by pneumococcal organisms.

5. What drives respiration in a patient with advanced chronic respiratory failure?

• A. Hypoxemia
• B. Hypocapnia
• C. Hypercapnia
• D. None of the above

Correct answer: A

Rationale: In patients with advanced chronic respiratory failure, such as those with chronic obstructive pulmonary disease (COPD), the respiratory drive shifts from being primarily stimulated by high levels of carbon dioxide (hypercapnia) to being driven by low oxygen levels (hypoxemia). This shift is due to the body's adaptation to chronic respiratory acidosis and hypoxemia. As a result, hypoxemia becomes the primary stimulus for respiration in these patients. Hypocapnia, a low level of carbon dioxide, is not a common driver of respiration in patients with advanced chronic respiratory failure. Therefore, the correct answer is hypoxemia.

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