Nursing Elites

1. A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?

• A. Immediately conduct a thorough assessment.
• B. Encourage visitors to distract the client.
• C. Provide a private room and limit stimulation.
• D. Speak softly to the client.

Correct answer: C

Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment. Therefore, the correct choice is to provide a private room and limit stimulation (option C) in this scenario.

2. A nurse receives a report about a client receiving IV fluids infusing at 125 mL/hr but notes they have only received 80 mL over the last 2 hours. What should the nurse do first?

• A. Check IV tubing for obstruction
• B. Increase the flow rate
• C. Change the IV site
• D. Notify the physician

Correct answer: A

Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.

3. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?

• A. BUN 15 mg/dL
• B. Creatinine 0.8 mg/dL
• C. Sodium 143 mEq/L
• D. Potassium 5.4 mEq/L

Correct answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.

4. A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the LPN/LVN monitor this client?

• A. Curling ulcer
• B. Renal shutdown
• C. Metabolic acidosis
• D. Hemolysis of red blood cells

Correct answer: C

Rationale: Corrected Rationale: Metabolic acidosis is a serious side effect of mafenide therapy that should be closely monitored. Mafenide can lead to metabolic acidosis due to its inhibition of carbonic anhydrase, resulting in the accumulation of carbonic acid. Curling ulcer (Choice A) is a stress-related mucosal lesion that occurs in the duodenum, primarily due to severe burns, not directly related to mafenide therapy. Renal shutdown (Choice B) is not a common side effect of mafenide therapy. Hemolysis of red blood cells (Choice D) is not a recognized side effect of mafenide cream application.

5. At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

• A. Stay with the client and offer assistance with relaxation techniques
• B. Assess the client's pain level and administer pain medication if needed
• C. Bring the client a prescribed PRN sedative-hypnotic
• D. Encourage the client to engage in a quiet, non-stimulating activity until feeling sleepy

Correct answer: C

Rationale: At 0100 on the client's second postoperative night, the nurse should address the client's inability to sleep. Providing a prescribed PRN sedative-hypnotic is appropriate in this situation to help the client rest. Choice A is incorrect because leaving the room and closing the door does not directly address the client's sleep concern. Choice B is not the priority at this moment since the client's main issue is insomnia, not pain. Choice D, while encouraging a non-stimulating activity, does not provide immediate relief for the client's sleeplessness as a sedative-hypnotic would.

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