Nursing Elites

1. Which action should the nurse include in the plan of care for a client receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?

• A. Initiate cardiac telemetry monitoring
• B. Maintain continuous pulse oximetry
• C. Perform capillary glucose measurements
• D. Monitor serum creatinine levels

Correct answer: D

Rationale: The correct answer is D: Monitor serum creatinine levels. Acyclovir can lead to nephrotoxicity, making it essential to monitor kidney function through serum creatinine levels. While cardiac telemetry monitoring (choice A) and maintaining continuous pulse oximetry (choice B) are important in certain conditions, they are not directly related to acyclovir therapy for herpes zoster. Performing capillary glucose measurements (choice C) is not a priority when administering acyclovir for herpes zoster. Monitoring serum creatinine levels is crucial to detect any potential renal issues early, as the drug's nephrotoxic potential requires close monitoring of kidney function.

2. Which client requires careful nursing assessment for signs and symptoms of hypomagnesemia?

• A. A young adult client with intractable vomiting from food poisoning
• B. A client who developed hyperparathyroidism in late adolescence
• C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
• D. A female client who is overzealous with her intake of simple carbohydrates

Correct answer: A

Rationale: The correct answer is A. Vomiting can lead to significant loss of magnesium, causing hypomagnesemia. In this scenario, the young adult client with intractable vomiting from food poisoning is at higher risk of developing hypomagnesemia due to the loss of magnesium through vomiting. Choices B, C, and D are less likely to present with hypomagnesemia. Hyperparathyroidism (B) is associated with hypercalcemia, renal failure (C) can lead to hypermagnesemia, and overconsumption of simple carbohydrates (D) is not directly linked to magnesium imbalances.

3. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication?

• A. Increased urinary clearance of the multiple medications has led to diuresis and lowered the blood pressure.
• B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness.
• C. The additive effect of multiple medications has caused the blood pressure to drop too low.
• D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.

Correct answer: C

Rationale: The correct answer is C. When a client experiences syncope due to a significant drop in blood pressure after receiving multiple antihypertensive medications, the additive effect of these medications can cause the blood pressure to drop excessively. This additive effect can lead to hypotension, which is why the nurse decided to hold the client's scheduled antihypertensive medication. Choices A, B, and D provide incorrect rationales. Choice A mentions diuresis, which is not directly related to the drop in blood pressure due to additive medication effects. Choice B refers to an antagonistic interaction reducing effectiveness, which is not applicable in this scenario. Choice D talks about a synergistic effect leading to drug toxicity, which is not the cause of the sudden drop in blood pressure observed in the client.

4. A 9-year-old received a short arm cast for a right radius. To relieve itching under the child’s cast, which instructions should the nurse provide to the parents?

• A. Blow cool air from a hair dryer under the cast
• B. Twist the cast back and forth
• C. Shake powder into the cast
• D. Push a pencil under the cast edge

Correct answer: A

Rationale: Blowing cool air from a hair dryer under the cast is a safe method to relieve itching without damaging the cast or causing injury. The air helps to dry out the moisture that is causing the itching. Twisting the cast back and forth (choice B) can create pressure points and discomfort for the child. Shaking powder into the cast (choice C) can introduce foreign material that may cause skin irritation. Pushing a pencil under the cast edge (choice D) can injure the child's skin or even dislodge the cast.

5. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?

• A. Assist the client in conserving energy during daily activities
• B. Explain to the client that this could be a side effect of the medication
• C. Assess the client for pallor
• D. Encourage the client to maintain a balanced diet and hydration

Correct answer: C

Rationale: The correct first intervention for a client with rheumatoid arthritis reporting increasing fatigue is to assess the client for pallor. Fatigue can be a sign of anemia or other complications; assessing for pallor can help determine if anemia is the cause. Option A is incorrect as it does not address the underlying cause of fatigue. Option B assumes the cause without further assessment. Option D is important for overall health but assessing for pallor takes precedence to identify immediate issues related to fatigue.

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