Nursing Elites

1. After assessing an older adult with a suspected cerebrovascular accident (CVA), the nurse documents the client's right upper arm weakness and slurred speech. When the client complains of a severe headache and nausea, and the neurological assessment remains unchanged, which action should the nurse implement first?

• A. Administer an oral analgesic with antiemetic
• B. Collect blood for coagulation times
• C. Send the client for a computed tomography scan of the brain
• D. Obtain a history of medication use, recent surgery, or injury

Correct answer: C

Rationale: In this scenario, the priority action for the nurse is to send the client for a computed tomography (CT) scan of the brain. A CT scan is crucial in assessing acute changes or bleeding that could influence treatment decisions in a suspected cerebrovascular accident (CVA). While addressing symptoms like headache and nausea is important, ruling out acute changes in the brain with a CT scan takes precedence in this situation. Collecting blood for coagulation times may be necessary but is not the initial priority. Obtaining a history of medication use, recent surgery, or injury is also important but not the first action to take when a CVA is suspected.

2. A young adult client was admitted 36 hours ago for a head injury that occurred as a result of a motorcycle accident. In the last 4 hours, the client’s urine output has increased to over 200 ml/hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

• A. Obtain capillary blood samples for glucose every 2 hours
• B. Measure oral secretions suctioned during the last 4 hours
• C. Evaluate the urine osmolality and serum osmolality values
• D. Obtain blood pressure and assess for dependent edema

Correct answer: C

Rationale: The correct answer is to evaluate the urine osmolality and serum osmolality values. The increased urine output following a head injury could indicate diabetes insipidus, a condition characterized by excessive urination and extreme thirst. Evaluating osmolality is crucial for diagnosing diabetes insipidus. Choice A is incorrect because obtaining capillary blood samples for glucose every 2 hours is not the priority in this situation. Choice B is irrelevant to the client's current symptom of increased urine output. Choice D is also not the most appropriate intervention as the focus should be on assessing for a potential endocrine issue related to the increased urine output.

3. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

• A. Altered consciousness within the first 24 hours after injury
• B. Confusion immediately following the injury
• C. Headache that resolves quickly
• D. Brief loss of consciousness with a lucid interval

Correct answer: A

Rationale: The correct answer is A. Epidural hematoma often presents with a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness. Therefore, altered consciousness within the first 24 hours after the injury is indicative of a developing epidural hematoma. Choices B, C, and D are incorrect because confusion immediately following the injury, headache that resolves quickly, and brief loss of consciousness with a lucid interval are not specific signs of epidural hematoma.

4. An 8-year-old child who weighs 60 pounds receives an order for Polycilin (Ampicillin) suspension 25 mg/kg/day divided into a dose every 8 hours. The medication is labeled '125 mg/5 ml'. How many ml should the nurse administer per dose every 8 hours?

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: Calculate the daily dose first: 60 pounds x 25 mg/kg = 1500 mg/day. Divide by 3 doses = 500 mg/dose. Convert to mL: (500 mg / 125 mg) x 5 ml = 20 ml. However, the question asks for the dose per administration every 8 hours, which is 1/3 of the daily dose. So, the correct calculation should be (20 ml / 3) = 6.67 ml, which rounds to 5 ml. Therefore, the correct answer is 5 ml. Choice B (10 ml) is incorrect because it doesn't consider the frequency of dosing. Choice C (15 ml) is incorrect as it overestimates the dose. Choice D (20 ml) is incorrect as it represents the total daily dose, not the dose per administration every 8 hours.

5. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer’s at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider?

• A. Gastric output of 900 mL in the last 24 hours
• B. Serum potassium level of 3.1 mEq/L or mmol/L (SI)
• C. Increased blood urea nitrogen (BUN)
• D. 24-hour intake at the current infusion rate

Correct answer: B

Rationale: The most crucial finding to report to the healthcare provider in this scenario is a serum potassium level of 3.1 mEq/L. Hypokalemia can lead to serious complications, including cardiac issues. Gastric output, increased BUN, and monitoring the 24-hour intake are essential but do not pose an immediate risk as hypokalemia does in this situation.

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