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. A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care?

• A. Right lower abdominal pain
• B. Confusion
• C. Depression
• D. Peripheral neuropathy

Correct answer: B

Rationale: Confusion is a key symptom of Wernicke’s syndrome, which is due to thiamine deficiency. Wernicke’s syndrome is characterized by a triad of symptoms known as the classic triad, which includes confusion, ataxia, and ophthalmoplegia. Right lower abdominal pain, depression, and peripheral neuropathy are not typically associated with Wernicke’s syndrome, making them incorrect choices for this question.

3. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

• A. Ask the client about gastrointestinal pain
• B. Measure the client’s fluid intake and output
• C. Monitor the client’s serum electrolyte levels
• D. Auscultate for bowel sounds in all quadrants

Correct answer: A

Rationale: The correct answer is A: Ask the client about gastrointestinal pain. The effectiveness of a proton pump inhibitor (PPI) is best evaluated by assessing the relief of gastrointestinal symptoms, such as heartburn, acid reflux, or stomach pain. These medications work by reducing the production of stomach acid, so improvement in these symptoms indicates the effectiveness of the PPI. Choices B, C, and D are incorrect because they do not directly reflect the effectiveness of a PPI. Measuring fluid intake and output, monitoring serum electrolyte levels, and auscultating for bowel sounds are important for assessing hydration status, electrolyte balance, and gastrointestinal motility, respectively. However, they are not specific to evaluating PPI effectiveness.

4. When implementing a disaster intervention plan, which intervention should the nurse implement first?

• A. Initiate the discharge of stable clients from hospital units
• B. Identify a command center where activities are coordinated
• C. Assess community safety needs impacted by the disaster
• D. Instruct all essential off-duty personnel to report to the facility

Correct answer: B

Rationale: When implementing a disaster intervention plan, the first step the nurse should take is to identify a command center where activities are coordinated. This step is crucial for ensuring an organized and effective disaster response. Option A, initiating the discharge of stable clients, is not a priority during the initial phase of disaster response. Option C, assessing community safety needs, usually follows setting up a command center. Option D, instructing off-duty personnel to report, may be necessary but is not the primary intervention at the beginning of a disaster situation.

5. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply).

• A. Practice relaxation exercises
• B. Limit fluids to avoid bladder distention
• C. Space activities to allow for rest periods
• D. Avoid persons with infections

Correct answer: A

Rationale: The correct instruction to include in the discharge plan for a client with MS to reduce symptom exacerbation is practicing relaxation exercises. Relaxation exercises can help manage MS symptoms by reducing stress. Limiting fluids to avoid bladder distention is not appropriate as adequate hydration is essential for overall health and helps prevent complications like urinary tract infections. While spacing activities to allow for rest periods can be beneficial for general well-being, it is not directly related to symptom exacerbation in MS. Avoiding persons with infections is important to prevent infections, but it is not specifically targeted at reducing MS symptom exacerbation.

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