Nursing Elites

1. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?

• A. Review the healthcare worker's history for possible exposure to TB.
• B. Instruct the healthcare worker to return for a repeat test in 1 week.
• C. Refer the healthcare worker to a healthcare provider for isoniazid (INH) therapy.
• D. Document negative results in the healthcare worker's medical record.

Correct answer: D

Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.

2. An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)

• A. Monitor electrolyte levels.
• B. Maintain pulse oximetry.
• C. Provide assistance with mobility.
• D. All of the Above

Correct answer: D

Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.

3. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?

• A. Increase intake of high-fiber foods, such as bran cereal
• B. Restrict protein intake by limiting meats and other high-protein foods.
• C. Limit oral fluid intake to 500ml per day
• D. Increase intake of potassium-rich foods such as bananas and cantaloupe.

Correct answer: B

Rationale: The correct answer is B: Restrict protein intake by limiting meats and other high-protein foods. In glomerulonephritis, reducing protein intake helps to lower the workload on the kidneys, as excessive protein can lead to increased production of waste products that the kidneys must filter. This restriction can help prevent further damage to the kidneys. Choices A, C, and D are incorrect because: A) Increasing high-fiber foods like bran cereal is beneficial for other conditions but not specific to glomerulonephritis. C) Limiting oral fluid intake to 500ml per day is not appropriate as fluid restrictions are usually individualized based on the client's condition and kidney function. D) Increasing potassium-rich foods like bananas and cantaloupe may not be suitable for all clients with glomerulonephritis, as potassium levels can be affected in kidney disease and individual needs may vary.

4. The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1,000 mL of gastric secretions were collected in the last 4 hours. The nurse should assess the client for symptoms of which related problem?

• A. Respiratory acidosis.
• B. Metabolic alkalosis.
• C. Hypoglycemia.
• D. Hyperkalemia.

Correct answer: B

Rationale: The correct answer is B: Metabolic alkalosis. Loss of gastric secretions can lead to metabolic alkalosis due to the loss of hydrochloric acid. This can result in an increase in blood pH levels. Respiratory acidosis (choice A) is caused by retention of carbon dioxide, not related to the loss of gastric secretions. Hypoglycemia (choice C) is a low blood sugar level and is not directly related to the loss of gastric secretions. Hyperkalemia (choice D) is an elevated potassium level in the blood and is not typically associated with the loss of gastric secretions.

5. A client with a history of seizures is prescribed phenytoin. Which side effect should the nurse instruct the client to report?

• A. Drowsiness
• B. Gingival hyperplasia
• C. Weight gain
• D. Blurred vision

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, which is an overgrowth of gum tissue. This side effect is important to report to the healthcare provider because it can lead to oral health problems. Choice A, drowsiness, is a common side effect of many antiepileptic drugs but is not specific to phenytoin. Choice C, weight gain, is not a typical side effect of phenytoin. Choice D, blurred vision, is not a common side effect of phenytoin; it is more commonly associated with other medications.

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