Nursing Elites

1. In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?

• A. Ineffective coping related to uncertainty of disease progression
• B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
• C. Ineffective breathing pattern related to ascending paralysis
• D. Impaired physical mobility related to asymmetrical descending paralysis

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.

2. The healthcare provider changes a client’s medication prescription from IV to PO administration and doubles the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduces bioavailability. What action should the nurse implement?

• A. Continue administering the medication via the IV route.
• B. Give half the prescribed oral dose until consulting the provider.
• C. Administer the medication orally as prescribed.
• D. Consult with the pharmacist regarding the prescription change.

Correct answer: D

Rationale: The correct action for the nurse to implement is to consult with the pharmacist regarding the change in prescription. With the high first-pass effect of the medication when given orally, it reduces its bioavailability, meaning a dosage adjustment may be necessary to achieve the desired therapeutic effect. Continuing to administer the medication via the IV route (choice A) is not appropriate as the prescription has been changed to oral administration. Giving half the prescribed oral dose until consulting the provider (choice B) is not recommended without proper guidance, which should come from consulting with the pharmacist. Simply administering the medication orally as prescribed (choice C) without addressing the potential issue of reduced bioavailability may lead to suboptimal treatment outcomes.

3. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home”. What response is best for the nurse to provide?

• A. Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your healthcare provider to discuss the possibility of receiving IV heparin therapy at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.

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. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

• A. Describe the safety of certain antianxiety medications during breastfeeding
• B. Encourage her to consider stress-relieving alternatives, such as deep breathing exercises
• C. Inform her that some antianxiety medications are safe to take while breastfeeding
• D. Explain that anxiety is a common response for the mother of a 3-week-old

Correct answer: C

Rationale: The correct answer is C. Some antianxiety medications are considered safe for use while breastfeeding, and the nurse should provide this information to alleviate the woman's concerns. Choice A has been corrected to focus on the safety of certain antianxiety medications during breastfeeding, which is more accurate. Choice B suggests stress-relieving alternatives, which may help but do not address the need for antianxiety medication if required. Choice D is incorrect because it minimizes the woman's concerns by dismissing her increased anxiety as a normal response.

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