Nursing Elites

1. The nurse is providing teaching to a patient who will begin taking a cephalosporin to treat an infection. Which statement by the patient indicates a need for further teaching?

• A. I may stop taking the medication if my symptoms clear up.
• B. I should eat yogurt while taking this medication.
• C. I should stop taking the drug and call my provider if I develop a rash.
• D. I will not consume alcohol while taking this medication.

Correct answer: A

Rationale: Patients should take all of an antibiotic regimen even after symptoms clear to ensure complete treatment of the infection.

2. What is the most common symptom of hypoglycemia that the nurse should teach the diabetic client to recognize?

• A. Nervousness
• B. Anorexia
• C. Kussmaul's respirations
• D. Bradycardia

Correct answer: A

Rationale: Nervousness is the most common symptom of hypoglycemia. It is often accompanied by other signs such as weakness, perspiration, confusion, and palpitations. Anorexia (lack of appetite) is not a typical symptom of hypoglycemia; it is more commonly associated with hyperglycemia. Kussmaul's respirations are a deep and labored breathing pattern seen in diabetic ketoacidosis, not hypoglycemia. Bradycardia (slow heart rate) is not a typical symptom of hypoglycemia; tachycardia (fast heart rate) is more commonly associated with hypoglycemia due to the release of catecholamines in response to low blood sugar.

3. After an endotracheal tube is placed in a client who experienced sudden onset of respiratory distress, what should the nurse do?

• A. Secure the tube in place with tape
• B. Order a chest x-ray for the client
• C. Document the depth of tube insertion
• D. Auscultate both lungs for breath sounds

Correct answer: D

Rationale: After endotracheal tube insertion, the nurse should auscultate both lungs for the presence of breath sounds. This step helps confirm proper tube placement and adequate ventilation. Auscultation of breath sounds is crucial to ensure that the tube is correctly positioned in the trachea and not in the esophagus. While securing the tube with tape is important, it is not the immediate priority after insertion. Ordering a chest x-ray may be necessary but is not the first action to take immediately post-intubation. Documenting the depth of tube insertion is important but ensuring proper ventilation through auscultation takes precedence.

4. A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?

• A. Check the client’s digoxin (Lanoxin) level.
• B. Administer an anti-nausea medication.
• C. Ask if the client can eat crackers.
• D. Refer the client to a gastrointestinal specialist.

Correct answer: A

Rationale: In a client with chronic kidney disease experiencing symptoms like nausea, vomiting, visual changes, and anorexia, it is crucial for the nurse to suspect digoxin (Lanoxin) toxicity. These symptoms are indicative of digoxin toxicity. Therefore, the best action for the nurse to take is to check the client's digoxin level. Administering anti-nausea medication, asking about eating crackers, and referring to a gastrointestinal specialist may help with symptom management but do not address the underlying cause of the symptoms, which is digoxin toxicity in this case.

5. A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?

• A. Use the catheter for the next laboratory blood draw.
• B. Monitor the central venous pressure through this line.
• C. Access the line for the next intravenous medication.
• D. Place a heparin or heparin/saline dwell after hemodialysis.

Correct answer: D

Rationale: The most appropriate action for the nurse after a central line catheter placement for hemodialysis is to place a heparin or heparin/saline dwell after hemodialysis treatment. This helps prevent clot formation in the line and maintain patency for future use. Using the catheter for blood draws is not recommended as it may increase the risk of infection. Monitoring central venous pressure is not indicated with this type of catheter. Accessing the line for medications is also not recommended to prevent complications and ensure the line is solely used for hemodialysis purposes.

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