Nursing Elites

1. A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, 'The client will verbalize symptoms of pacemaker failure.' Which symptoms are most important to teach the client?

• A. Facial flushing.
• B. Fever.
• C. Pounding headache.
• D. Feelings of dizziness.

Correct answer: D

Rationale: The correct answer is 'D: Feelings of dizziness.' Feelings of dizziness may occur as a result of a decreased heart rate, leading to decreased cardiac output, which can be an indication of pacemaker failure. Teaching the client to recognize symptoms of decreased cardiac output, like dizziness, is crucial for early detection of pacemaker malfunction. Choices A, B, and C are less specific to pacemaker failure and are not commonly associated with this condition. Facial flushing, fever, and pounding headache are not typical signs of pacemaker failure and are not directly related to cardiac output, making them less relevant for teaching the client about pacemaker failure.

2. The nurse is preparing to give trimethoprim-sulfamethoxazole (TMP-SMX) to a patient and notes a petechial rash on the patient’s extremities. The nurse will perform which action?

• A. Hold the dose and notify the provider.
• B. Request an order for a blood glucose level.
• C. Request an order for a BUN and creatinine level.
• D. Request an order for diphenhydramine (Benadryl).

Correct answer: A

Rationale: When a patient on TMP-SMX presents with a petechial rash, it can be indicative of a severe adverse reaction such as thrombocytopenia or a hypersensitivity reaction. The appropriate action for the nurse to take in this situation is to hold the dose of TMP-SMX and notify the healthcare provider immediately. This is crucial to prevent further administration of a medication that may be causing a serious adverse effect. Requesting a blood glucose level (Choice B) is not relevant in this scenario as the patient's presentation is suggestive of a skin-related issue rather than a glucose-related problem. Similarly, requesting a BUN and creatinine level (Choice C) would not address the immediate concern of a petechial rash and its association with TMP-SMX. Requesting an order for diphenhydramine (Choice D) may help manage itching or mild allergic reactions but is not the priority when a petechial rash is observed, as it may indicate a more severe reaction requiring immediate intervention.

3. A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?

• A. Assessing the client’s chest for crepitus every 24 hours
• B. Taping the connections between the chest tube and the drainage system
• C. Adding 20 mL of sterile water to the suction control chamber every shift
• D. Recording the volume of secretions in the drainage collection chamber every 24 hours

Correct answer: B

Rationale: The correct action for the nurse to take in caring for a client with a chest tube connected to a closed chest drainage system is to tape the connections between the chest tube and the drainage system. This is done to prevent accidental disconnection, ensuring the system functions properly. Assessing the client’s chest for crepitus should be done more frequently than once every 24 hours to monitor for any air leaks. Adding sterile water to the suction control chamber is not necessary every shift; it should be done as needed to maintain the appropriate water level. Recording the volume of secretions in the drainage collection chamber should be done more frequently than every 24 hours, with hourly monitoring during the first 24 hours after insertion and every 8 hours thereafter to assess for changes or complications.

4. A client is receiving continuous ambulatory peritoneal dialysis. Which of the following statements indicates the need for more teaching by the nurse?

• A. I should take all my medications every morning.
• B. The catheter should always remain in place.
• C. The catheter should be flushed daily with sterile saline.
• D. If I gain 2 pounds, I should skip dialysis that day.

Correct answer: D

Rationale: The correct answer is D. Gaining weight is a sign that the client may be retaining fluid, indicating a need for dialysis to remove excess fluid. Skipping dialysis based on weight gain can lead to fluid overload, electrolyte imbalances, and other serious complications. Choices A, B, and C are all correct statements regarding peritoneal dialysis care: taking medications as prescribed is essential for overall health, ensuring the catheter remains in place is crucial to prevent infection, and flushing the catheter with sterile saline daily helps maintain its patency and reduce the risk of infections.

5. A client with acute glomerulonephritis (GN) is being evaluated by a nurse. Which manifestation should the nurse recognize as a positive response to the prescribed treatment?

• A. The client has lost 11 pounds in the past 10 days.
• B. The client’s urine specific gravity is 1.048.
• C. No blood is observed in the client’s urine.
• D. The client’s blood pressure is 152/88 mm Hg.

Correct answer: A

Rationale: A weight loss of 11 pounds in the past 10 days indicates fluid loss, a positive response to treatment for acute glomerulonephritis. It signifies that the glomeruli are functioning adequately to filter excess fluid. A urine specific gravity of 1.048 is high, indicating concentrated urine, which is not a positive response in this context. Blood in the urine is not a typical finding in glomerulonephritis, so its absence is expected and does not indicate a positive response to treatment. A blood pressure of 152/88 mm Hg is elevated and may suggest kidney damage or fluid overload, which are not positive responses to treatment.

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