Nursing Elites

1. The client is being discharged after a concussion. Which of the following symptoms should be reported?

• A. Difficulty waking up
• B. Headache (3/10 on the pain scale)
• C. Bruising on knees and elbows
• D. Achy feeling all over

Correct answer: A

Rationale: The correct answer is 'Difficulty waking up' because it indicates a change in consciousness, which is a concerning symptom following a concussion. Reporting this symptom is crucial as it may signify a more severe head injury. 'Headache (3/10 on the pain scale)' may be common after a concussion but is not as urgent as a change in consciousness. 'Bruising on knees and elbows' is likely unrelated to the concussion and not a priority for reporting. 'Achy feeling all over' is a vague symptom and not specific to a concerning change in the client's condition post-concussion.

2. What is the primary sign of displacement following a total hip replacement?

• A. pain on movement and weight bearing
• B. hemorrhage
• C. affected leg appearing 1-2 inches longer
• D. edema in the area of the incision

Correct answer: A

Rationale: The correct answer is pain on movement and weight bearing. This pain is the primary sign of prosthesis displacement after a total hip replacement, indicating pressure on nerves or muscles due to dislocation. Hemorrhage is not typically associated with prosthesis displacement. While the affected leg may appear longer, this is not the primary sign of displacement; it might actually be shorter due to muscle spasm. Edema in the incision area is not a primary indicator of prosthesis displacement.

3. Acyclovir is the drug of choice for:

• A. HIV
• B. HSV 1 and 2 and VZV
• C. CMV
• D. influenza A viruses

Correct answer: C

Rationale: Acyclovir (Zovirax) is specifically used to treat infections caused by herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) and varicella-zoster virus (VZV). These include conditions like cold sores, genital herpes, and shingles. Acyclovir works by inhibiting viral DNA replication, leading to the formation of shorter, ineffective DNA chains. It is important to note that acyclovir is not effective against other viruses like HIV, cytomegalovirus (CMV), or influenza A viruses. Therefore, the correct answer is HSV 1 and 2 and VZV.

4. A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?

• A. A weight greater than 10 lbs. should be used.
• B. The line of pull is upward at an angle.
• C. The line of pull is straight
• D. A weight greater than 20 lbs. should be used.

Correct answer: C

Rationale: The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.

5. Assessment of the client with an arteriovenous fistula for hemodialysis should include:

• A. inspection for visible pulsations.
• B. palpation of thrill.
• C. percussion for dullness.
• D. auscultation of blood pressure.

Correct answer: B

Rationale: The correct answer is to palpate for a thrill. A thrill should be present in a functioning arteriovenous fistula (AVF) and indicates good blood flow. The client should be educated to check for this sensation daily at home to monitor the AVF's patency. Visible pulsations are not typically observed in an AVF. Percussion for dullness does not provide relevant information about the AVF. Auscultation of blood pressure is not a standard practice in assessing an AVF. However, auscultation of the AVF for a bruit, a sound indicating turbulent blood flow, is crucial in evaluating the AVF's patency.

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