Nursing Elites

1. Which medication should the nurse withhold if the client's blood pressure is 88/50?

• A. Rosuvastatin (Crestor)
• B. Enalapril (Vasotec)
• C. Digoxin (Lanoxin)
• D. Clopidogrel (Plavix)

Correct answer: B

Rationale: Enalapril (Vasotec) is the correct answer. It is an angiotensin-converting enzyme (ACE) inhibitor that can further lower blood pressure. Given that the client's blood pressure is already low at 88/50, administering Enalapril could exacerbate hypotension and compromise perfusion to vital organs. Rosuvastatin (Crestor), Digoxin (Lanoxin), and Clopidogrel (Plavix) are not contraindicated in the context of low blood pressure and may be administered safely.

2. Which electrolyte imbalance would be the nurse's priority concern in the burn client?

• A. Hypernatremia
• B. Hyperkalemia
• C. Hypoalbuminemia
• D. Hypermagnesemia

Correct answer: B

Rationale: The correct answer is hyperkalemia. In a burn client, the nurse's priority concern is hyperkalemia due to cell lysis, which releases potassium into the bloodstream. This can lead to dangerous levels of potassium in the blood. Hypernatremia (Choice A) is less likely in burn clients. Hypoalbuminemia (Choice C) can occur but is not the priority in the immediate management of a burn client. Hypermagnesemia (Choice D) is not typically associated with burn injuries.

3. Which of the following food selections would need to be removed from a tray for a client recovering from thyroidectomy?

• A. Fresh apple
• B. V8 juice
• C. Mustard greens
• D. Ice cream

Correct answer: A

Rationale: The correct answer is a fresh apple. After a thyroidectomy, it is important to avoid hard and crunchy foods like apples due to the proximity of the esophagus to the surgical site. Apples can be difficult to chew and swallow, posing a risk of injury or discomfort to the patient. V8 juice, mustard greens, and ice cream are softer options that would be more suitable for a client recovering from thyroidectomy.

4. What is an appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus?

• A. Insertion of a Foley catheter.
• B. Performing an in-and-out catheter specimen for urinalysis.
• C. Obtaining a voided urine specimen for urinalysis.
• D. Ordering a urinalysis by the physician.

Correct answer: D

Rationale: When a client presents with suspected genitourinary trauma and visible blood at the urethral meatus, obtaining a voided urine specimen for urinalysis is an appropriate intervention. This helps assess for any urinary tract injuries or abnormalities without further traumatizing the area. Insertion of a Foley catheter (Choice A) should be avoided as it can worsen the existing trauma. Performing an in-and-out catheter specimen (Choice B) involves unnecessary manipulation and can increase the risk of complications. Ordering a urinalysis by the physician (Choice D) may delay the assessment compared to obtaining a direct voided urine specimen.

5. A 62-year-old female is being seen on a home visit by a nurse. The patient reports she has been taking Premarin for years. Which of the following would indicate an overdose?

• A. Lower extremity edema
• B. Sensory changes in the upper extremities
• C. Increased occurrence of fractures
• D. Decreased peripheral blood flow

Correct answer: A

Rationale: Lower extremity edema can indicate an overdose of Premarin. Premarin, an estrogen hormone replacement therapy, can cause fluid retention leading to edema in the lower extremities. Sensory changes in the upper extremities, increased occurrence of fractures, and decreased peripheral blood flow are not typically associated with an overdose of Premarin.

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