Nursing Elites

1. The nurse is assessing a client who has a new cast on the left arm. Which finding should the nurse report to the healthcare provider immediately?

• A. Client reports itching under the cast
• B. Client reports pain at the cast site
• C. Client reports swelling of the fingers
• D. Client reports warmth over the casted area

Correct answer: C

Rationale: Swelling of the fingers can indicate compromised circulation, which is a serious concern in a client with a new cast. It could suggest the development of compartment syndrome, a condition where increased pressure within the muscles can lead to impaired blood flow. This can result in tissue damage and should be addressed promptly. Itching under the cast, pain at the cast site, and warmth over the casted area are common findings after cast application and may not necessarily indicate an urgent issue requiring immediate reporting to the healthcare provider.

2. A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?

• A. Watch training videos of people driving in various environments
• B. Begin visualizing himself driving each route to the freeway
• C. Take antianxiety medication two hours before driving on freeways
• D. Get in the car with a support person and drive on a freeway during rush hour

Correct answer: B

Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.

3. A 9-year-old boy with tetralogy of Fallot is being discharged following a cardiac catheterization. Which discharge instruction should the nurse provide the parents?

• A. Do not allow the child to return to school for at least one month
• B. Notify the healthcare provider if there is any drainage at the catheterization site
• C. Monitor the child's temperature and report any elevation
• D. Observe for any changes in the child's color or energy level

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider if there is any drainage at the catheterization site. Drainage at the site can be a sign of infection, which needs prompt evaluation and treatment. Choices A, C, and D are not as crucial as identifying and reporting any drainage, which is more directly related to potential complications post-cardiac catheterization.

4. A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?

• A. Offer to obtain a new breakfast tray in an hour so the client can take the Zithromax
• B. Instruct the client to eat his breakfast and take the Zithromax two hours after eating
• C. Tell the client to skip that day's dose and resume taking the Zithromax the next day
• D. Provide a PRN dose of an antacid to take with the Zithromax right after breakfast

Correct answer: B

Rationale: To ensure the effectiveness of the antibiotic and manage blood glucose levels, the client should take the Zithromax two hours after eating. Option A is incorrect because obtaining a new breakfast tray is not necessary to administer the missed dose. Option C is incorrect as skipping a dose can lead to decreased effectiveness of the antibiotic. Option D is incorrect because providing an antacid is not indicated in this situation.

5. When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?

• A. When did your symptoms first begin?
• B. Can you describe the pain and how it feels?
• C. Do you have any changes in vision?
• D. Have you experienced any seizures?

Correct answer: D

Rationale: The correct answer is D. When assessing a client diagnosed with a brain tumor, asking about seizures is crucial because they can be a common symptom associated with brain tumors. Seizures in this context could provide valuable information regarding the progression and impact of the brain tumor on the client's neurological status. Choices A, B, and C are important questions in a general assessment, but when specifically focusing on a client with a brain tumor, inquiring about seizures takes priority due to its direct relevance to the condition.

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