Nursing Elites

1. When should the nurse conduct an Allen’s test?

• A. When obtaining pulmonary artery pressures
• B. To assess for the presence of a deep vein thrombus in the leg
• C. Just before arterial blood gases are drawn peripherally
• D. Prior to attempting a cardiac output calculation

Correct answer: C

Rationale: The correct time to conduct an Allen’s test is just before arterial blood gases are drawn peripherally. This test is performed to assess the adequacy of collateral circulation in the hand before obtaining arterial blood gases. Choice A is incorrect because an Allen’s test is not specifically done when obtaining pulmonary artery pressures. Choice B is incorrect because an Allen’s test is not used to assess deep vein thrombosis. Choice D is incorrect because an Allen’s test is not done specifically before attempting a cardiac output calculation.

2. The client who had a below-the-knee (BKA) amputation is being prepared for discharge to home. Which recommendation should the nurse provide this client?

• A. Inspect skin for redness
• B. Use a residual limb shrinker
• C. Apply alcohol to the stump after bathing
• D. Wash the stump with soap and water

Correct answer: D

Rationale: The correct recommendation for a client with a below-the-knee amputation preparing for discharge is to wash the stump with soap and water. This helps maintain cleanliness and prevent infection. Inspecting the skin for redness is important to monitor for signs of infection, but it is not a specific recommendation for a BKA amputation. Using a residual limb shrinker can aid in shaping and reducing swelling in the residual limb but is not usually done immediately after a BKA amputation. Applying alcohol to the stump after bathing is not recommended as it can lead to skin irritation and dryness.

3. When a UAP reports to the charge nurse that a client has a weak pulse with a rate of 44 beats per minute, what action should the charge nurse implement?

• A. Instruct the UAP to count the client's apical pulse rate for sixty seconds.
• B. Determine if the UAP also measured the client's capillary refill time.
• C. Assign a practical nurse (LPN) to determine if an apical radial pulse deficit is present.
• D. Notify the health care provider of the abnormal pulse rate and pulse volume.

Correct answer: D

Rationale: The correct action for the charge nurse to implement is to notify the health care provider of the abnormal pulse rate and pulse volume. A weak pulse with bradycardia (pulse rate of 44 beats per minute) requires immediate follow-up to investigate potential underlying issues. In this situation, it is crucial to involve the healthcare provider for further assessment and intervention. Instructing the UAP to count the client's apical pulse rate for sixty seconds (Choice A) may delay necessary actions. Determining capillary refill time (Choice B) is not directly related to addressing a weak pulse, and assigning an LPN to assess an apical radial pulse deficit (Choice C) is not as urgent as involving the healthcare provider.

4. While a patient is receiving beta-1b interferon every other day for multiple sclerosis, which serum laboratory test findings should the nurse monitor to assess for possible bone marrow suppression caused by the medication? (Select all that apply)

• A. Platelet count
• B. White blood cell count (WBC)
• C. Sodium and potassium
• D. Red blood cell count (RBC)

Correct answer: A

Rationale: Beta-1b interferon can lead to bone marrow suppression, impacting blood cell production. Therefore, monitoring the platelet count, white blood cell count (WBC), and red blood cell count (RBC) is essential. Platelet count is a direct indicator of bone marrow function and can show early signs of bone marrow suppression. While sodium, potassium, and albumin/protein levels are important for overall health assessment, they are not directly associated with bone marrow suppression caused by the medication.

5. A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?

• A. Tell the client to have a complete blood count (CBC) drawn
• B. Instruct the client to seek medical attention immediately
• C. Encourage them to take the medication at night with a snack
• D. Explain that these are common side effects of the medication

Correct answer: B

Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.

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