Nursing Elites

1. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?

• A. Diazepam IV
• B. Lorazepam PO
• C. Diltiazem IV
• D. Clonazepam PO

Correct answer: A

Rationale: In the scenario described, where the client has been experiencing repeated tonic-clonic seizures over an extended period, the priority is to administer a medication that can rapidly terminate the seizures. Diazepam is the medication of choice for status epilepticus due to its rapid onset of action within 10 minutes when administered intravenously. Lorazepam is also an option, but it is typically administered intravenously as well. Diltiazem is a calcium channel blocker used for conditions like hypertension and angina, not for seizures. Clonazepam, although used for seizures, is not the ideal choice in this acute situation due to its slower onset of action compared to benzodiazepines like diazepam and lorazepam.

2. What teaching should be provided to a patient following an escharotomy for burn injuries?

• A. Monitor for infection
• B. Restrict fluid intake
• C. Avoid physical activity
• D. Limit phosphorus to 1,500 mg/day

Correct answer: A

Rationale: Following an escharotomy for burn injuries, patients should be taught to monitor for infection and care for the incision site. Choice A is the correct answer because infection is a common risk after a procedure involving incisions. Choices B, C, and D are incorrect. Restricting fluid intake is not typically advised after an escharotomy; avoiding physical activity may vary depending on the individual's condition and should be guided by healthcare providers; and limiting phosphorus to 1,500 mg/day is not directly related to post-escharotomy care.

3. What intervention is needed for continuous bubbling in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Clamp the chest tube
• C. Replace the chest tube system
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: The correct intervention for continuous bubbling in the chest tube water seal chamber is to tighten the connections of the chest tube system. Continuous bubbling indicates an air leak in the system, and tightening the connections can help resolve this issue. Clamping the chest tube (Choice B) is not appropriate and can lead to complications by obstructing the drainage system. Similarly, replacing the entire chest tube system (Choice C) may not be necessary if the issue can be resolved by tightening the connections. Continuing to monitor the chest tube (Choice D) without taking action to address the continuous bubbling may delay necessary interventions to prevent complications.

4. What is the priority action if a patient experiences hypoglycemia after an insulin dose?

• A. Check the patient's blood glucose level
• B. Administer IV dextrose
• C. Document the incident
• D. Continue monitoring the patient

Correct answer: A

Rationale: The priority action when a patient experiences hypoglycemia after an insulin dose is to check the patient's blood glucose level. This is crucial to confirm hypoglycemia before initiating any treatment. While administering IV dextrose may be necessary if the patient's blood glucose level is critically low, confirming hypoglycemia is essential to guide appropriate interventions. Documenting the incident is important for documentation purposes but is not the immediate priority when the patient's safety is at risk. Continuing to monitor the patient is essential, but it should follow the confirmation and initial management of hypoglycemia.

5. What are the expected symptoms in a patient with a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Sudden loss of consciousness
• C. Severe headache and confusion
• D. Loss of sensation in the affected limb

Correct answer: A

Rationale: A thrombotic stroke typically presents with a gradual loss of function on one side of the body. This gradual onset distinguishes it from a hemorrhagic stroke, which often manifests with sudden and severe symptoms like loss of consciousness (choice B), severe headache and confusion (choice C), or loss of sensation in the affected limb (choice D). Therefore, choices B, C, and D are not typically associated with thrombotic strokes.

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