Nursing Elites

1. A client is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

• A. The client is experiencing an adverse reaction to rifampin.
• B. The client's seizure disorder is no longer under control.
• C. The client is showing evidence of phenytoin toxicity.
• D. The client is having adverse effects due to combination antimicrobial therapy.

Correct answer: C

Rationale: Ataxia and incoordination are signs of phenytoin toxicity rather than adverse reactions to rifampin or isoniazid. These symptoms indicate that the client is experiencing an adverse effect of phenytoin, requiring a dose adjustment. Choice A is incorrect because rifampin is not typically associated with ataxia and incoordination. Choice B is incorrect as the development of ataxia and incoordination does not necessarily mean the seizure disorder is no longer under control. Choice D is incorrect as the symptoms are more indicative of phenytoin toxicity rather than adverse effects of combination antimicrobial therapy.

2. What are the nursing interventions for a patient experiencing hypoglycemia?

• A. Administer glucose or dextrose and monitor blood sugar levels
• B. Monitor vital signs and provide a high-carbohydrate snack
• C. Monitor for sweating and confusion
• D. Provide insulin and assess for hyperglycemia

Correct answer: A

Rationale: The correct answer is A. Administering glucose or dextrose is a crucial nursing intervention for a patient experiencing hypoglycemia as it helps to quickly raise blood sugar levels. Monitoring blood sugar levels is essential to ensure that the patient's glucose levels normalize. Choice B is incorrect because providing a high-carbohydrate snack may not be sufficient to rapidly raise blood sugar levels in severe hypoglycemia. Choice C is incorrect because while monitoring for sweating and confusion is important in hypoglycemia, it is not a direct nursing intervention. Choice D is incorrect as providing insulin would lower blood sugar levels further, worsening hypoglycemia.

3. A healthcare professional is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer?

• A. Family history of asthma
• B. Elevated BMI
• C. History of travel
• D. High cholesterol

Correct answer: B

Rationale: Elevated BMI is a significant risk factor for colorectal cancer. Excess body weight, especially around the waist, increases the risk of developing this type of cancer. Family history of asthma (Choice A) is not directly related to colorectal cancer risk. History of travel (Choice C) and high cholesterol (Choice D) are also not established risk factors for colorectal cancer.

4. What is the most important intervention when managing a client with delirium?

• A. Administer a sedative to reduce agitation
• B. Identify any reversible causes of delirium
• C. Increase environmental stimulation
• D. Limit noise and provide a calm environment

Correct answer: B

Rationale: The correct answer is B: 'Identify any reversible causes of delirium.' When managing a client with delirium, it is crucial to first identify and address any reversible factors contributing to the delirium. Administering sedatives (Choice A) may worsen delirium and is not the primary intervention. Increasing environmental stimulation (Choice C) can exacerbate symptoms. Limiting noise and providing a calm environment (Choice D) are beneficial but not as crucial as identifying reversible causes.

5. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?

• A. Canned soup
• B. Grilled chicken
• C. Peanut butter
• D. Orange juice

Correct answer: B

Rationale: Grilled chicken is the correct choice as it is a low-potassium, low-sodium option suitable for clients with chronic kidney disease. Canned soup (choice A) is typically high in sodium, which is not recommended for this client population. Peanut butter (choice C) is high in potassium and phosphorus, which should be limited in individuals with kidney disease. Orange juice (choice D) is high in potassium and should be consumed in moderation by clients with chronic kidney disease.

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