Nursing Elites

1. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?

• A. Administer antiseizure medications promptly.
• B. Use oral airway devices during seizures.
• C. Pad the side rails of the bed.
• D. Apply restraints during the seizure to prevent injury.

Correct answer: C

Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.

2. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?

• A. Respiratory rate of 60/min
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.

3. A client has been prescribed albuterol. Which of the following is a priority adverse effect the nurse should monitor?

• A. Tachycardia
• B. Bradycardia
• C. Dizziness
• D. Hypertension

Correct answer: A

Rationale: Corrected Rationale: Albuterol, a beta-2 adrenergic agonist, can lead to tachycardia due to its stimulant effect on beta-2 receptors in the heart. Monitoring for tachycardia is crucial as it can be a sign of excessive sympathetic stimulation and may lead to severe complications. Bradycardia, dizziness, and hypertension are less likely adverse effects of albuterol, making them lower priority for monitoring in this context.

4. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

• A. Distended, board-like abdomen
• B. WBC count of 15,000/mm³
• C. Rebound tenderness over McBurney’s point
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: A distended, board-like abdomen is a concerning sign indicating the possibility of a ruptured appendix and peritonitis, which are medical emergencies. Reporting this finding immediately is crucial for prompt intervention. Choice B, an elevated WBC count, could indicate infection but is not as urgent as the risk of a ruptured appendix. Choice C, rebound tenderness over McBurney’s point, is a classic sign of appendicitis but does not indicate an immediate threat like a possible rupture. Choice D, a slightly elevated temperature, is a nonspecific finding and not as critical as the risk of peritonitis associated with a distended, board-like abdomen.

5. A nurse is assessing a client with chronic kidney disease. Which laboratory value would indicate the need for hemodialysis?

• A. Glomerular filtration rate (GFR) of 14 mL/min
• B. BUN 16 mg/dL
• C. Serum magnesium 1.8 mg/dL
• D. Serum phosphorus 4.0 mg/dL

Correct answer: A

Rationale: A GFR of 14 mL/min indicates significant kidney damage and a severe decrease in kidney function. This level of GFR typically indicates the need for hemodialysis to help the kidneys perform their function adequately. BUN, serum magnesium, and serum phosphorus levels are important in assessing kidney function and managing chronic kidney disease but do not specifically indicate the need for hemodialysis. Therefore, choices B, C, and D are incorrect.

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