Nursing Elites

1. A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?

• A. Ambulate with a walker for upper body support
• B. Perform abdominal curls to stretch the back muscles
• C. Position in semi-Fowler's with the knees flexed
• D. Encourage straight leg raises while lying supine

Correct answer: C

Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.

2. A child with heart failure (HF) is taking digitalis. Which sign indicates to the nurse that the child may be experiencing digitalis toxicity?

• A. Tachycardia
• B. Dyspnea
• C. Vomiting
• D. Muscle cramps

Correct answer: C

Rationale: Vomiting is a common sign of digitalis toxicity and should be closely monitored. While tachycardia is a common sign of heart failure, it is not typically associated with digitalis toxicity (Choice A). Dyspnea (Choice B) and muscle cramps (Choice D) are not specific signs of digitalis toxicity and can be present in other conditions. Therefore, the presence of vomiting should raise concerns about digitalis toxicity in the child with heart failure.

3. A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?

• A. Administer the infusion via an infusion pump
• B. Obtain the current serum potassium level
• C. Continuously monitor blood pressure
• D. Teach guided imagery to decrease pain

Correct answer: C

Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.

4. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory value requires intervention by the nurse?

• A. Total calcium 9 mg/dl (2.25 mmol/L SI)
• B. Creatinine 4 mg/dl (354 micromol/L SI)
• C. Phosphate 4 mg/dl (1.293 mmol/L SI)
• D. Fasting glucose 95 mg/dl (5.3 mmol/L SI)

Correct answer: B

Rationale: An elevated creatinine level indicates possible renal impairment, which requires intervention. High creatinine levels are associated with decreased kidney function, and in this case, it suggests potential renal issues due to long-term corticosteroid therapy. Monitoring renal function is crucial in clients with osteoporosis on corticosteroid therapy to prevent further complications. Total calcium levels within the normal range are suitable for a client with osteoporosis receiving calcium carbonate. Phosphate and fasting glucose levels do not directly indicate renal impairment in this scenario.

5. A premature infant weighing 1,200 grams at birth receives a prescription for beractant (Survanta) 120 mg endotracheal now and q6 hr for 24 hr. The recommended dose for beractant is 100 mg/kg birth weight per dose. Single-use vials of Survanta are labeled 100 mg/4 ml. What action should the nurse take?

• A. Give 4.8 ml q6 hr
• B. Notify the healthcare provider that the dose is too high
• C. Notify the healthcare provider that the dose is too low
• D. Give 1.2 ml q6 hr

Correct answer: A

Rationale: The correct answer is to give 4.8 ml q6 hr. To calculate the dose, you divide the prescribed dose of 120 mg by the concentration of Survanta, which is 100 mg per 4 ml. This results in 4.8 ml per dose, as 120 mg ÷ 100 mg/4 ml = 4.8 ml. Option B suggesting to notify the healthcare provider that the dose is too high is incorrect because the calculated dose of 4.8 ml is based on the recommended dose of 100 mg/kg birth weight. Option C suggesting to notify the healthcare provider that the dose is too low is incorrect as the calculated dose is based on the correct dosage calculation. Option D suggesting to give 1.2 ml q6 hr is incorrect because it doesn't align with the correct calculation.

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