Nursing Elites

1. A client admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

• A. Patch one eye.
• B. Reorient often.
• C. Range of motion.
• D. Evaluate swallow

Correct answer: B

Rationale: Frequent reorientation is crucial for clients with neurological impairments from osmotic demyelination to prevent confusion and assist with orientation. It helps maintain a proper sense of time, place, and person, reducing disorientation. Patching one eye (Choice A) is not a priority intervention for osmotic demyelination and does not address the immediate need for reorientation. Range of motion exercises (Choice C) may be important for overall care, but reorientation takes precedence due to its impact on neurological functioning. Evaluating swallow (Choice D) is not the primary intervention needed for osmotic demyelination; it is essential but not the first priority.

2. The nurse is planning care for a family whose children did not receive childhood immunizations. After one of the children contracted mumps, the father is diagnosed with orchitis. Which intervention should be included in the father's plan of care?

• A. Use of bedrest with scrotal support
• B. Administration of antibiotics for 10 days
• C. Applying heat to promote the healing process
• D. Using an ice pack to reduce scrotal pain

Correct answer: A

Rationale: For orchitis, the recommended intervention is bedrest with scrotal support. This helps reduce swelling and discomfort in the scrotum. Antibiotics are generally not required for viral orchitis, so administering antibiotics for 10 days (Choice B) is not indicated. Applying heat (Choice C) may worsen swelling and should be avoided. Using an ice pack (Choice D) is not the preferred method for managing orchitis; it may not be as effective as providing support and rest for the scrotum.

3. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

• A. Intravenous administration of thyroid hormones
• B. Oral administration of hypnotic agents
• C. Intravenous bolus of hydrocortisone
• D. Subcutaneous administration of vitamin K

Correct answer: A

Rationale: The correct answer is A: Intravenous administration of thyroid hormones. Myxedema coma is a severe form of hypothyroidism that necessitates immediate replacement of thyroid hormones. Administering thyroid hormones intravenously ensures rapid absorption and effectiveness in managing the condition. Choice B, oral administration of hypnotic agents, is incorrect as it does not address the primary issue of thyroid hormone deficiency in myxedema coma. Choice C, intravenous bolus of hydrocortisone, is not the appropriate treatment for myxedema coma as adrenal insufficiency is not the primary concern in this condition. Choice D, subcutaneous administration of vitamin K, is unrelated to the management of myxedema coma and does not address the underlying thyroid hormone deficiency that characterizes this condition.

4. An adult client presents to the clinic with large draining ulcers on both lower legs that are characteristic of Kaposi’s Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take?

• A. Obtain a blood sample to determine if the client is HIV positive
• B. Send the family to the waiting area while conducting a head-to-toe assessment
• C. Complete a head-to-toe assessment to identify other signs of HIV
• D. Ask the family members to wear gloves when touching the client

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to complete a head-to-toe assessment to identify other signs of HIV. Kaposi’s Sarcoma is commonly associated with HIV infection, and conducting a comprehensive assessment can provide crucial information on potential signs and symptoms related to HIV. This information is essential for providing appropriate care and treatment. Option A is not the priority at this moment, as the focus should be on assessing the client comprehensively first. Sending the family members away (Option B) may not be necessary if they are not interfering with the assessment process. While infection control is important, asking the family members to wear gloves (Option D) is not the most critical action to take in this situation.

5. After receiving report, which client should the nurse assess last?

• A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
• B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
• C. An older client with a distended abdomen and no drainage from the nasogastric tube
• D. An adult client with rectal tube draining clear pale red liquid drainage

Correct answer: D

Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.

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