Nursing Elites

1. Which action should the school nurse take first when conducting a screening for scoliosis?

• A. Compare dorsal trunk measurements
• B. Have the individual extend arms over the head for visualization
• C. Inspect for symmetrical shoulder height
• D. Observe weight-bearing on each leg

Correct answer: C

Rationale: Inspecting for symmetrical shoulder height is a crucial initial step in screening for scoliosis. Asymmetry in shoulder height can indicate the presence of spinal curvature, which is a key indicator of scoliosis. This assessment is prioritized as it provides a visual clue to potential spinal abnormalities. Choices A, B, and D are not the first steps in scoliosis screening. Choice A involves a more detailed measurement that is not the primary visual indicator for scoliosis; choice B is not a primary indicator of scoliosis but can be used for further examination, and choice D is not directly related to identifying spinal curvature.

2. 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.

3. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?

• A. Lorazepam (Ativan)
• B. Famotidine (Pepcid)
• C. Thiamine (Vitamin B1)
• D. Atenolol (Tenormin)

Correct answer: C

Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.

4. The client with a mechanical valve replacement understands the discharge teaching when the client makes which statement?

• A. ''I will need to take antibiotics before any type of invasive dental work''
• B. ''I will not have to take any more heart medication since I have a new valve''
• C. ''I will need to have this valve replaced in about 10 years''
• D. ''I should notify my healthcare provider if I hear a clicking sound near my heart''

Correct answer: A

Rationale: The correct answer is A. Clients with mechanical valve replacements need to take prophylactic antibiotics before dental procedures to prevent endocarditis. Choice B is incorrect because even with a new valve, heart medications may still be necessary to manage the condition. Choice C is incorrect because mechanical valves typically do not need replacement as frequently as within 10 years. Choice D is incorrect because hearing a clicking sound near the heart could indicate valve malfunction, not just the need to notify the healthcare provider.

5. The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?

• A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet
• B. Estimate the blood pressure by assessing the pulse volume of the client’s radial pulses
• C. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed
• D. Document why the blood pressure cannot be accurately measured at the present time

Correct answer: D

Rationale: When a client cannot have their blood pressure measured due to specific circumstances such as casts on both arms, the nurse should document the reason why the blood pressure cannot be obtained accurately. This documentation is crucial for maintaining a clear record of the client's condition and for continuity of care. Advising the UAP to document the last blood pressure obtained (Choice A) does not address the current inability to measure the blood pressure. Estimating the blood pressure by assessing the pulse volume of radial pulses (Choice B) is not a reliable method for obtaining accurate blood pressure readings. Demonstrating how to palpate the popliteal pulse (Choice C) is irrelevant in this situation as it does not provide a solution for accurately measuring the blood pressure.

Similar Questions