Nursing Elites

1. A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?

• A. Call the surgeon immediately.
• B. Administer Extra Strength Tylenol per orders.
• C. Assess the surgical site.
• D. Offer extra blankets and increase fluids.

Correct answer: A

Rationale:

2. Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?

• A. Transfuse neutrophils (granulocytes) to prevent infection.
• B. Exclude raw vegetables from the diet.
• C. Avoid administering rectal suppositories.
• D. Prohibit vases of fresh flowers and plants in the client's room.

Correct answer: A

Rationale: The correct answer is to transfuse neutrophils (granulocytes) to prevent infection. Granulocyte transfusion is not routinely indicated to prevent infection in neutropenic clients. While neutrophils are essential in fighting infections and are beneficial in selected populations of infected, severely granulocytopenic clients who do not respond to antibiotics and are expected to experience prolonged suppression of granulocyte production, routine granulocyte transfusion is not recommended. Choices B, C, and D are appropriate interventions for a severely neutropenic client. Prohibiting fresh flowers and plants helps reduce the risk of exposure to environmental pathogens. Avoiding rectal suppositories minimizes the risk of introducing harmful bacteria. Excluding raw vegetables from the diet reduces the likelihood of foodborne infections.

3. A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?

• A. hyperkalemia
• B. hypernatremia
• C. hypokalemia
• D. hypomagnesemia

Correct answer: C

Rationale: When a client is receiving drug therapy with furosemide and digitalis, the nurse should anticipate the development of hypokalemia due to the potassium-wasting effects of furosemide. Hypokalemia can potentiate digitalis toxicity. While hyperkalemia is a concern with some medications, it is not typically associated with furosemide and digitalis. Furosemide can lead to hyponatremia, not hypernatremia, due to its diuretic effect. Hypomagnesemia, though a possible imbalance, is not the most likely to occur in this scenario as furosemide and digitalis are more commonly associated with hypokalemia.

4. While Fluorouracil (5FU®) is being infused, a client complains of burning at the IV site. What should the nurse do first?

• A. Aspirate the IV site for blood return.
• B. Slow the infusion.
• C. Inspect the IV site.
• D. Stop the infusion.

Correct answer: C

Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (Choice A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (Choice B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (Choice D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.

5. A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?

• A. Polyphagia
• B. Polyuria
• C. Metabolic acidosis
• D. Lower extremity edema

Correct answer: D

Rationale: Polyphagia, polyuria, and metabolic acidosis are common clinical signs of diabetes mellitus. Polyphagia refers to excessive hunger, polyuria is excessive urination, and metabolic acidosis can occur due to poorly controlled diabetes. Lower extremity edema, on the other hand, is not a typical clinical sign of diabetes mellitus. Edema in the lower extremities is more commonly associated with conditions like heart failure or kidney disease rather than diabetes mellitus.

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