Nursing Elites

1. The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?

• A. Assess extremity strength and resistance
• B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
• C. Measure and record the cardiac QRS complex
• D. Check current finger stick glucose

Correct answer: D

Rationale: The client’s symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.

2. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client’s right leg?

• A. Dorsiflexes the right foot and left foot on command
• B. A 3 by 5 cm ecchymosis area on the right calf
• C. Right calf is 3 cm larger in circumference than the left calf
• D. Bilateral lower extremities have 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant difference in calf circumference between the legs is a classic sign of DVT. This is due to the obstruction of blood flow in the deep veins of the leg, leading to swelling in the affected limb. Choices A, B, and D are not typical findings of DVT. Choice A describes a neurological response, choice B indicates a bruise on the right calf, and choice D describes pitting edema in both lower extremities, which are not specific signs of DVT.

3. The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12-hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 ml, and voids twice. The dry diaper weighs 105 grams. Which computer documentation should the nurse enter in the infant’s record?

• A. Subtract vomitus from 120 ml Pedialyte, then document 95 ml oral intake.
• B. Compare the difference between the infant’s current weight and admission weight.
• C. Document on the flow sheet that the infant voided twice and vomited 25 ml.
• D. Calculate the difference in wet and dry diapers and document 80 ml urine.

Correct answer: C

Rationale: The correct answer is to document on the flow sheet that the infant voided twice and vomited 25 ml. This choice accurately reflects the need for accurate documentation of intake and output, essential for monitoring the infant's hydration status. Choice A is incorrect because the oral intake should not be calculated by subtracting vomitus from the oral intake. Choice B is incorrect because it does not address the specific documentation related to the infant's output. Choice D is incorrect as it focuses on calculating urine output based on diaper weight, which is not the primary concern in this scenario.

4. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?

• A. Instruct the client to perform cough and deep breathing exercises
• B. Assess the client’s vital signs and respiratory effort
• C. Administer oxygen via nasal cannula according to the PNR protocol
• D. Document assessment findings in the client’s medical record

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.

5. A client is admitted with pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?

• A. Tissue sloughing upon extravasation
• B. Elevated blood pressure and heart rate
• C. Tinnitus and vertigo
• D. Erythema of the face, neck, and chest

Correct answer: C

Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.

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