Nursing Elites

1. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?

• A. The client's extremities are paralyzed.
• B. The peripheral nerve stimulator causes twitching.
• C. The client clenches fist upon command.
• D. The client's Glasgow Coma Scale score is 14.

Correct answer: A

Rationale: The correct answer is A. Tubocurarine chloride is a neuromuscular blocker that works by causing paralysis of skeletal muscles. Therefore, if the client's extremities are paralyzed, it indicates that the medication is effective in achieving the desired muscle relaxation necessary for mechanical ventilation. Choices B and C are incorrect as they suggest muscle activity, which would not be expected with the administration of a neuromuscular blocker. Choice D is unrelated to the effectiveness of tubocurarine chloride.

2. A 45-year-old obese man arrives at a clinic reporting daytime sleepiness, difficulty falling asleep at night, and snoring. The nurse should recognize the manifestations of what health problem?

• A. Adenoiditis
• B. Chronic tonsillitis
• C. Obstructive sleep apnea
• D. Laryngeal cancer

Correct answer: C

Rationale: The symptoms described, including daytime sleepiness, difficulty falling asleep at night, and snoring, are classic signs of obstructive sleep apnea. This condition is commonly seen in obese individuals due to the relaxation of throat muscles during sleep, leading to airway obstruction. Adenoiditis and chronic tonsillitis are less likely as they don't typically present with the same symptoms mentioned.

3. A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which dietary instruction should the nurse provide?

• A. Avoid foods high in vitamin K.
• B. Increase intake of dairy products.
• C. Limit intake of citrus fruits.
• D. Avoid high-sodium foods.

Correct answer: A

Rationale: Patients on warfarin should avoid foods high in vitamin K because vitamin K can interfere with the anticoagulant effect of the medication. Warfarin works by inhibiting vitamin K-dependent clotting factors, so consuming large amounts of vitamin K-rich foods may decrease the effectiveness of the medication. Choices B, C, and D are incorrect. Increasing intake of dairy products, limiting citrus fruits, or avoiding high-sodium foods are not directly related to the mechanism of action of warfarin or its dietary considerations.

4. A 48-year-old woman presents with fatigue, pruritus, and jaundice. She has a history of ulcerative colitis. Laboratory tests reveal elevated bilirubin and alkaline phosphatase. What is the most likely diagnosis?

• A. Hepatitis B
• B. Primary biliary cirrhosis
• C. Primary sclerosing cholangitis
• D. Autoimmune hepatitis

Correct answer: C

Rationale: The combination of symptoms (fatigue, pruritus, jaundice) along with a history of ulcerative colitis and elevated bilirubin and alkaline phosphatase levels suggests primary sclerosing cholangitis. Primary sclerosing cholangitis is commonly associated with inflammatory bowel disease, such as ulcerative colitis. It is characterized by inflammation and fibrosis of the bile ducts, leading to cholestasis and elevated alkaline phosphatase and bilirubin levels.

5. A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?

• A. Administer regular insulin intravenously.
• B. Give oral hypoglycemic agents.
• C. Administer sodium bicarbonate.
• D. Provide a high-calorie diet.

Correct answer: A

Rationale: The priority nursing action for a patient with type 1 diabetes mellitus admitted with diabetic ketoacidosis (DKA) is to administer regular insulin intravenously. Insulin helps to lower blood glucose levels and correct acidosis, which are critical in managing DKA. Administering oral hypoglycemic agents is not appropriate in the acute setting of DKA as they may not work quickly enough compared to intravenous insulin. While sodium bicarbonate may be used to correct acidosis, insulin administration is the priority to address both hyperglycemia and acidosis simultaneously. Providing a high-calorie diet is not suitable initially in DKA management; the main focus is on stabilizing the patient's condition through insulin therapy and fluid/electrolyte correction.

Similar Questions