Nursing Elites

1. What is a priority intervention for a patient experiencing a thyroid storm?

• A. Administering antipyretics.
• B. Cooling the patient.
• C. Administering beta-blockers.
• D. Administering antithyroid medications.

Correct answer: D

Rationale: During a thyroid storm, the priority intervention is to administer antithyroid medications to reduce thyroid hormone levels quickly. These medications, such as propylthiouracil or methimazole, help inhibit the production of thyroid hormones. Administering antipyretics (choice A) may help reduce fever, but it does not address the underlying cause of the thyroid storm. Cooling the patient (choice B) may provide symptomatic relief but does not address the thyroid hormone dysregulation. Administering beta-blockers (choice C) can help manage symptoms like tachycardia and hypertension, but it does not target the root cause of the thyroid storm.

2. Which of the following is a priority intervention for a patient with suspected sepsis?

• A. Administering antibiotics.
• B. Administering IV fluids.
• C. Administering antipyretics.
• D. Monitoring blood cultures.

Correct answer: D

Rationale: Monitoring blood cultures is a crucial intervention in suspected sepsis because it helps identify the causative organism, which is essential for guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important but should be guided by blood culture results. Administering IV fluids (Choice B) is also essential to support hemodynamic stability in sepsis. Administering antipyretics (Choice C) may help reduce fever but is not a priority compared to identifying the causative organism through blood cultures.

3. The patient is receiving a high dose of intravenous azithromycin to treat an infection and taking acetaminophen for pain. The nurse should expect to review which lab values when monitoring for this drug’s side effects?

• A. Complete blood counts
• B. Electrolytes
• C. Liver enzymes
• D. Urinalysis

Correct answer: C

Rationale: When a patient is receiving a high dose of intravenous azithromycin, which is a macrolide antibiotic, in combination with acetaminophen, a potentially hepatotoxic drug, the nurse should monitor liver enzymes. High doses of macrolides when taken with hepatotoxic drugs like acetaminophen can lead to hepatotoxicity. Reviewing liver enzymes helps in early detection of liver damage. Complete blood counts (Choice A) are not typically affected by azithromycin or acetaminophen. Electrolytes (Choice B) are not directly impacted by these medications. Urinalysis (Choice D) is not specifically indicated for monitoring the side effects of azithromycin and acetaminophen combination therapy.

4. A client is being taught about self-catheterization in the home setting. Which statements should the nurse include in this client’s teaching? (Select all that apply.)

• A. Wash your hands before and after self-catheterization.
• B. Use lubricant on the tip of the catheter before insertion.
• C. A & B
• D. Self-catheterize at least twice a day or every 12 hours.

Correct answer: C

Rationale: In teaching a client about self-catheterization, it is essential to emphasize proper hand hygiene before and after the procedure to prevent infections. Using lubricant on the catheter helps with insertion and reduces discomfort. Therefore, statements A and B are correct and should be included in the client's teaching. Option D is incorrect because self-catheterization frequency should be individualized based on the client's needs, and a specific time frame like every 12 hours may not be suitable for everyone. Choosing a smaller lumen catheter is preferred over a larger one. Self-catheterization should not be limited to a specific time frame but should be based on the individual's needs and voiding patterns. Therefore, option C is the correct choice as it includes the two essential statements for teaching self-catheterization in the home setting.

5. Which of the following is a sign of hypocalcemia?

• A. Hyperactive reflexes.
• B. Depressed reflexes.
• C. Muscle cramps.
• D. Seizures.

Correct answer: A

Rationale: Hyperactive reflexes are a classic sign of hypocalcemia. Hypocalcemia leads to increased neuromuscular excitability, resulting in hyperactive reflexes. Depressed reflexes (Choice B) are not typically associated with hypocalcemia. Muscle cramps (Choice C) can be seen in hypocalcemia due to muscle irritability but are not a specific sign. Seizures (Choice D) can occur in severe cases of hypocalcemia but are not as common as hyperactive reflexes.

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