Nursing Elites

1. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.

2. The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?

• A. Initiation of the impulses from a location outside the SA node
• B. Inability of the SA node to initiate an impulse at the normal rate
• C. Increased conduction time from the SA node to the AV junction
• D. Interference with the conduction through one or both ventricles

Correct answer: C

Rationale: When the PR interval is prolonged, it signifies an increased conduction time from the SA node through the AV junction. This finding is characteristic of a first-degree heart block where there is a delay in the electrical conduction at the level of the AV node. Choices A, B, and D are incorrect as they do not accurately reflect the significance of a prolonged PR interval.

3. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding indicates the need for immediate intervention?

• A. Use of accessory muscles
• B. Oxygen saturation of 94%
• C. Carbon dioxide level of 45 mmHg
• D. Respiratory rate of 20 breaths per minute

Correct answer: C

Rationale: A carbon dioxide level of 45 mmHg is concerning in a client with COPD receiving supplemental oxygen, as it may indicate carbon dioxide retention and requires immediate intervention. Options A, B, and D are not the priority findings in this scenario. While the use of accessory muscles, an oxygen saturation of 94%, and a respiratory rate of 20 breaths per minute are important to monitor in a client with COPD, they do not indicate an immediate need for intervention like an elevated carbon dioxide level does.

4. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding requires immediate intervention?

• A. Increased fatigue
• B. Elevated blood pressure
• C. Headache
• D. Elevated hemoglobin

Correct answer: A

Rationale: The correct answer is A, 'Increased fatigue.' In a client with CKD receiving erythropoietin therapy, increased fatigue can be a sign of polycythemia, a condition characterized by an elevated red blood cell count. This can lead to increased blood viscosity and raise the risk of thromboembolic events, necessitating immediate intervention. Elevated blood pressure (choice B) is a common concern in CKD but does not require immediate intervention in this context. Headache (choice C) may be related to elevated blood pressure but is not the most critical finding requiring immediate attention. Elevated hemoglobin (choice D) is an expected outcome of erythropoietin therapy and does not require immediate intervention unless excessively high.

5. A client with a history of heart failure presents to the clinic with nausea, vomiting, yellow vision, and palpitations. Which finding is most important for the nurse to assess for this client?

• A. Assess distal pulses and signs of peripheral edema
• B. Determine the client's level of orientation and cognition
• C. Obtain a list of medications taken for cardiac history
• D. Ask the client about exposure to environmental heat

Correct answer: C

Rationale: The correct answer is to obtain a list of medications taken for cardiac history. The client's presentation is indicative of digitalis toxicity, commonly associated with medications like digoxin (Lanoxin) used in heart failure treatment. Understanding the client's medication history, particularly the use of digoxin, is crucial in confirming and managing digitalis toxicity. Assessing distal pulses and signs of peripheral edema (Choice A) may be relevant in heart failure but are not the priority in this case. Determining the client's level of orientation and cognition (Choice B) and asking about exposure to environmental heat (Choice D) are not directly related to the client's current symptoms and are less pertinent in this scenario.

Similar Questions