Nursing Elites

1. A nurse in an emergency department is caring for a client who reports cocaine use 1 hour ago. Which of the following findings should the nurse expect?

• A. Hypotension.
• B. Memory loss.
• C. Slurred speech.
• D. Elevated temperature.

Correct answer: D

Rationale: The correct answer is D: Elevated temperature. Cocaine is a stimulant drug that can lead to increased body temperature. Hypotension (Choice A) is less likely as cocaine tends to elevate blood pressure. Memory loss (Choice B) and slurred speech (Choice C) are more commonly associated with depressant drugs rather than stimulant drugs like cocaine.

2. A nurse is teaching a prenatal class about infection. Which statement by the client indicates further teaching is required?

• A. I can visit someone with chickenpox 5 days after the sores crust.
• B. I should avoid eating foods that contain high folic acid.
• C. I can clean my cat's litter box during pregnancy.
• D. I should wash my hands with hot water for 10 seconds after gardening.

Correct answer: C

Rationale: The correct answer is C because cleaning a cat's litter box during pregnancy can increase the risk of toxoplasmosis, which can be harmful to the developing fetus. Choice A is correct as the statement indicates understanding of the chickenpox transmission timeline. Choice B is also correct as high folic acid foods are beneficial during pregnancy. Choice D is correct as washing hands with hot water after gardening helps prevent infections.

3. A nurse is assessing a client who has a history of seizure disorder and is receiving phenytoin. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Bradycardia.
• B. Ataxia.
• C. Tachycardia.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Ataxia. Ataxia, which refers to uncoordinated movements, is a common adverse effect of phenytoin, a medication used to manage seizure disorders. Bradycardia (Choice A) is not typically associated with phenytoin; instead, it may cause tachycardia (Choice C) as a side effect. Insomnia (Choice D) is not a common adverse effect of phenytoin.

4. A client receiving morphine via patient-controlled analgesia (PCA) should have naloxone administered if their respiratory rate is below 10/min. What action should the nurse take?

• A. Monitor the client's blood pressure every 4 hours.
• B. Ask the client to rate their pain every 2 hours.
• C. Administer naloxone if the client's respiratory rate is below 10/min.
• D. Evaluate the client's use of the PCA every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to administer naloxone if the client's respiratory rate falls below 10/min. Naloxone is used to reverse opioid-induced respiratory depression, which is a life-threatening situation. Monitoring the client's blood pressure every 4 hours (Choice A) is not the priority in this scenario as respiratory depression requires immediate attention. Asking the client to rate their pain every 2 hours (Choice B) is important for pain management but addressing respiratory depression takes precedence. Evaluating the client's use of the PCA every 4 hours (Choice D) is a routine nursing intervention but does not directly address the urgent need to reverse respiratory depression in this case.

5. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 10 mL of water after feeding
• B. Flush the tube with 30 mL of water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.

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