Nursing Elites

1. The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

• A. Low-grade fever
• B. Bruising of the skin
• C. Abdominal cramping
• D. Bloody emesis

Correct answer: D

Rationale: The correct answer is D: Bloody emesis. Bloody emesis indicates potential bleeding or severe irritation, which should be reported immediately. In the context of acute gastritis, bloody emesis could indicate a more serious complication that requires urgent medical attention. Choices A, B, and C are not typically associated with acute gastritis caused by contaminated water and do not signal as critical of a condition as bloody emesis. Low-grade fever, bruising of the skin, and abdominal cramping are more commonly associated with other conditions or may be less urgent in this context.

2. A client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take?

• A. Explain the importance of regular dressing changes
• B. Administer an anti-anxiety medication
• C. Proceed with the scheduled dressing change
• D. Encourage the client to express any anxieties

Correct answer: A

Rationale: In this situation, the most important action for the nurse to take is to explain the importance of regular dressing changes to the client. By doing so, the nurse can help the client understand the necessity for wound healing and infection prevention. Administering anti-anxiety medication (Choice B) may not address the root cause of the client's anxiety, which is the lack of understanding. Proceeding with the scheduled dressing change (Choice C) without addressing the client's concerns can worsen their anxiety and decrease trust. Encouraging the client to express any anxieties (Choice D) is important but not as crucial as ensuring the client comprehends the rationale behind the dressing change.

3. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

• A. Check the visual difficulties
• B. Note the most recent hemoglobin level
• C. Assess for hand and joint pain
• D. Observe rhythm on telemetry monitor

Correct answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

4. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be infused over 4 hours. The IV administration set delivers 10gtt/ml. How many gtt/minute should the nurse regulate the infusion? (Enter a numeric value only. If rounding is required, round to the nearest whole number.)

• A. 42
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the rate: (1000 ml / 4 hours) = 250 ml/hour; (250 ml/hour) / (60 minutes/hour) = 4.17 ml/minute; (4.17 ml/minute) * (10 gtt/ml) = 41.7 gtt/minute, rounded to 42 gtt/minute. Therefore, the nurse should regulate the infusion at 42 gtt/minute to deliver the prescribed fluid challenge accurately. The other choices are incorrect as they do not reflect the correct calculation based on the given information.

5. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbecue that afternoon. What question is most important for the triage nurse to ask this client?

• A. Have you recently traveled outside the United States?
• B. How high was your temperature when you returned home?
• C. Have you taken any medication to treat these symptoms?
• D. Is anyone else sick who was also at the picnic?

Correct answer: D

Rationale: The most important question for the triage nurse to ask the client in this scenario is whether anyone else who attended the picnic is also sick. This is crucial to identify a potential outbreak or common source of infection. Asking about recent travel may be important for infectious diseases but is not as relevant as identifying a common source among individuals who shared the same food. Inquiring about the client's temperature is important but does not provide immediate insight into the cause of symptoms. Asking about medication taken is relevant but not as critical as determining if others are affected, which could indicate a foodborne illness.

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