Nursing Elites

1. The charge nurse observes that a client with a nasogastric tube on low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What action should the nurse take?

• A. Remove the glass of water and speak to the UAP.
• B. Discuss the incident with the UAP at the end of the day.
• C. Write an incident report and notify the healthcare provider.
• D. Remind the client of the potential for electrolyte imbalance.

Correct answer: A

Rationale: The correct action for the charge nurse to take is to remove the glass of water and speak to the UAP. This ensures immediate correction and education to prevent further issues with the nasogastric tube. Addressing the situation promptly can prevent harm to the client and reinforces the importance of following proper protocols.

2. A client with a history of chronic alcohol use is admitted with confusion and an unsteady gait. Which deficiency should the nurse suspect?

• A. Thiamine (Vitamin B1)
• B. Cyanocobalamin (Vitamin B12)
• C. Folic acid
• D. Vitamin D

Correct answer: A

Rationale: The correct answer is Thiamine (Vitamin B1). Chronic alcohol use can lead to thiamine deficiency, which can result in neurological symptoms such as confusion and an unsteady gait. Thiamine is essential for proper brain function and nerve conduction, and its deficiency is common in individuals with alcohol use disorder. Cyanocobalamin (Vitamin B12) deficiency can also present with neurological symptoms, but in this case, the patient's history of chronic alcohol use points more towards thiamine deficiency. Folic acid deficiency typically presents with symptoms like fatigue and megaloblastic anemia. Vitamin D deficiency is associated with bone health issues rather than neurological symptoms.

3. A patient with systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine. What is the most important instruction the nurse should give?

• A. Report any vision changes immediately.
• B. Take the medication with milk.
• C. Avoid high-fat foods.
• D. Increase intake of green leafy vegetables.

Correct answer: A

Rationale: The correct instruction for a patient prescribed hydroxychloroquine, especially in the context of systemic lupus erythematosus (SLE), is to report any vision changes immediately. Hydroxychloroquine can potentially cause retinal damage, so prompt reporting and ophthalmologic evaluation are essential in preventing irreversible eye complications. Choices B, C, and D are incorrect because they do not address the significant adverse effect of hydroxychloroquine on vision. Taking the medication with milk, avoiding high-fat foods, or increasing intake of green leafy vegetables are not relevant to the primary concern of monitoring for visual changes.

4. Which problem in a client requires the most immediate intervention by the nurse?

• A. Finger paresthesias related to carpal tunnel syndrome.
• B. Increasing sharp pain related to compartment syndrome.
• C. Increasing burning pain related to a Morton's neuroma.
• D. Increasing sharp pain related to plantar fasciitis.

Correct answer: B

Rationale: The correct answer is B: Increasing sharp pain related to compartment syndrome. Compartment syndrome is a serious condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. Immediate intervention is crucial to prevent permanent damage to muscles and nerves, including tissue necrosis and nerve injury. Choices A, C, and D do not present the same level of urgency as compartment syndrome, making them less critical for immediate intervention. Carpal tunnel syndrome, Morton's neuroma, and plantar fasciitis may cause discomfort and functional limitations but are not typically considered emergencies requiring urgent intervention like compartment syndrome.

5. The client has undergone a thyroidectomy, and the nurse is providing care. Which assessment finding requires immediate intervention?

• A. Hoarseness and a sore throat.
• B. Difficulty swallowing.
• C. Numbness and tingling around the mouth.
• D. Temperature of 100.2°F (37.9°C).

Correct answer: C

Rationale: Numbness and tingling around the mouth can indicate hypocalcemia, a common complication post-thyroidectomy due to inadvertent parathyroid gland removal. Immediate intervention is required to prevent severe hypocalcemia manifestations like tetany or seizures. Hoarseness and a sore throat are common after a thyroidectomy due to surgical trauma and irritation to the vocal cords, not requiring immediate intervention. Difficulty swallowing can be expected due to postoperative swelling or edema, but it should be monitored closely. A temperature of 100.2°F is a mild fever and may be a normal postoperative response, not necessitating immediate intervention unless accompanied by other concerning symptoms.

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