Nursing Elites

1. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Watery diarrhea
• B. Nausea
• C. Headache
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention. Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.

2. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?

• A. Encourage the client to drink plenty of fluids.
• B. Perform deep suctioning every 2 to 4 hours.
• C. Increase humidity in the client's room.
• D. Administer a mucolytic agent.

Correct answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.

3. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?

• A. INR of 3.5
• B. Prothrombin time (PT) of 15 seconds
• C. Headache
• D. Blood pressure of 140/90 mmHg

Correct answer: C

Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.

4. A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse where she is. What information is most important for the nurse to obtain?

• A. History of alcohol use
• B. Current medication list
• C. Baseline cognitive status
• D. Family history of dementia

Correct answer: A

Rationale: The correct answer is A: History of alcohol use. In this scenario, obtaining the history of alcohol use is crucial as it could indicate withdrawal, which might explain the client's confusion. Alcohol withdrawal can lead to symptoms such as confusion, agitation, and disorientation. While knowing the current medication list (choice B) is important for overall patient care, in this case, alcohol withdrawal is a more likely cause of the confusion. Baseline cognitive status (choice C) is valuable for comparison but may not directly explain the sudden confusion. Family history of dementia (choice D) is less relevant in this acute situation compared to the potential immediate impact of alcohol withdrawal.

5. An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

• A. Destruction of joint cartilage.
• B. Inflammation of synovial membrane.
• C. Formation of bone spurs.
• D. Reduction of joint space.

Correct answer: A

Rationale: Corrected Rationale: Osteoarthritis typically involves the destruction of joint cartilage, leading to pain and stiffness. This destruction of joint cartilage results in bone rubbing against bone, causing pain and reduced mobility. Choices B, C, and D are incorrect. Inflammation of the synovial membrane (choice B) is more commonly associated with rheumatoid arthritis. Formation of bone spurs (choice C) and reduction of joint space (choice D) are manifestations that can occur as a result of osteoarthritis but are not the primary pathology responsible for the symptoms of pain and stiffness.

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