Nursing Elites

1. Which symptom is the client who self-administered an overdose of acetaminophen most likely to exhibit?

• A. Pink frothy sputum
• B. Seizure activity
• C. Jaundiced conjunctiva
• D. Diaphoresis and fever

Correct answer: C

Rationale: When a client self-administers an overdose of acetaminophen, the liver is primarily affected. Jaundiced conjunctiva, which is yellowing of the eyes, is a common symptom of liver damage. Pink frothy sputum is typically associated with conditions like pulmonary edema, not acetaminophen overdose. Seizure activity is not a common symptom of acetaminophen overdose but can be seen in other toxicities. Diaphoresis and fever are more generalized symptoms and not specific to acetaminophen overdose.

2. Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?

• A. mycobacterium tuberculosis
• B. clostridium tetani
• C. staphylococcus aureus
• D. human immunodeficiency virus

Correct answer: C

Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.

3. A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?

• A. Note in medication records the drug given
• B. The client was not hurt, no need for documentation
• C. Note the client's orientation
• D. Completely fill out an incident report

Correct answer: D

Rationale: In the case where medications are given to the wrong client, the appropriate documentation by the nurse should involve completely filling out an incident report. This report is essential for tracking errors, implementing corrective measures, and ensuring patient safety. Choice A is incorrect because solely noting the drug given does not address the severity of the error. Choice B is incorrect because even if the client was not hurt, documentation is crucial for quality improvement and risk prevention. Choice C is incorrect as noting the client's orientation does not adequately address the medication error and its implications.

4. When teaching bleeding precautions to a client with leukemia, the PN should include which of the following instructions?

• A. Use a soft toothbrush.
• B. Use dental floss daily.
• C. Hold pressure on any scrapes for 1-2 minutes.
• D. Use a triple-edged razor.

Correct answer: A

Rationale: The correct answer is to 'Use a soft toothbrush.' A soft toothbrush is recommended because it is less likely to cause the gums to bleed in clients with leukemia, who are at risk of bleeding due to overcrowding of white cells at the expense of other cell types like platelets. Choice B, 'Use dental floss daily,' is incorrect because dental floss is contraindicated and can make the gums bleed in clients with leukemia. Choice C, 'Hold pressure on any scrapes for 1-2 minutes,' is incorrect because when clotting is impaired, pressure should be held for 5-10 minutes or longer until the bleeding stops. Choice D, 'Use a triple-edged razor,' is incorrect because an electric razor should be used instead of a triple-edged razor to prevent small cuts and bleeding in clients with leukemia.

5. Which of the following arterial blood gas values indicates a patient may be experiencing a condition of metabolic acidosis?

• A. PaO2 90 mm Hg
• B. Bicarbonate 15 mEq/L
• C. CO2 47 mm Hg
• D. pH 7.34

Correct answer: B

Rationale: The correct answer is B: Bicarbonate 15 mEq/L. In metabolic acidosis, the bicarbonate levels are lower than normal. A bicarbonate value of 15 mEq/L indicates a deficit in the buffer system, contributing to the acidosis. Choices A, C, and D are incorrect. Choice A, PaO2 90 mm Hg, reflects oxygen partial pressure and is not directly related to metabolic acidosis. Choice C, CO2 47 mm Hg, represents carbon dioxide levels and is more indicative of respiratory status. Choice D, pH 7.34, falls within the normal range (7.35-7.45) and does not confirm metabolic acidosis.

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