Nursing Elites

1. After a motor vehicle collision, a client is admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement?

• A. Determine serum glucose levels
• B. Withhold potassium additives to IV fluids
• C. Give IV corticosteroid replacement
• D. Prepare to initiate IV vasopressors

Correct answer: C

Rationale: In a client with acute adrenal insufficiency (Addisonian crisis) following a motor vehicle collision, the priority intervention is to administer IV corticosteroid replacement. This is crucial to manage the crisis by replacing the deficient cortisol. Determining serum glucose levels (Choice A) may be important but is not the immediate priority in this situation. Withholding potassium additives to IV fluids (Choice B) is not indicated and may exacerbate electrolyte imbalances. Initiating IV vasopressors (Choice D) is not the primary treatment for acute adrenal insufficiency and should be reserved for managing hypotension that is unresponsive to corticosteroid therapy.

2. A client receives a prescription for acetylcysteine (Mucomyst) 1.4 grams per nasogastric tube q4 hours. Acetylcysteine is available as a 10% solution (10 grams/100ml). How many ml of the 10% solution should the nurse administer per dose?

• A. 7
• B. 10
• C. 14
• D. 1.4 grams of acetylcysteine is equivalent to 14 ml of a 10% solution.

Correct answer: D

Rationale: To determine the amount of the 10% acetylcysteine solution to administer, convert the 1.4 grams to milligrams (1.4 grams = 1400 mg). Then, as the 10% solution contains 10 grams (10,000 mg) per 100 ml, it means there are 1000 mg of acetylcysteine in every 10 ml of the solution (10,000 mg / 100 ml = 100 mg/ml). Therefore, to administer 1400 mg (1.4 grams) of acetylcysteine, the nurse should give 14 ml of the 10% solution. Choices A, B, and C are incorrect as they do not accurately convert the amount of acetylcysteine to the corresponding volume of the 10% solution.

3. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

4. Identify the placement of the stapes footplate into the bony labyrinth.

• A. Fenestra vestibuli
• B. Fenestra cochleae
• C. Tympanic membrane
• D. Round window

Correct answer: A

Rationale: The correct answer is A: Fenestra vestibuli. The stapes footplate is placed into the fenestra vestibuli of the bony labyrinth. This structure is also known as the oval window and is located at the junction of the middle ear and inner ear. Choice B, Fenestra cochleae, is incorrect as this opening is also known as the round window and is located near the base of the cochlea. Choice C, Tympanic membrane, is incorrect as it is also known as the eardrum and separates the external ear from the middle ear. Choice D, Round window, is incorrect as it is the opening covered by the secondary tympanic membrane and is important for the dissipation of sound waves in the cochlea.

5. When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?

• A. The presence and location of any pressure ulcers.
• B. Measures already taken to maintain client safety.
• C. Any special mattresses on the client’s bed.
• D. Current vital signs and oxygen saturation.

Correct answer: B

Rationale: The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.

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