Nursing Elites

1. The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?

• A. Record usual eating patterns
• B. Evaluate for muscle cramping
• C. Document abdominal girth
• D. Elevate both legs on pillows

Correct answer: B

Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.

2. What should the nurse do to complete a focused assessment for a female client with inflamed and painful hemorrhoids?

• A. Determine if the client uses any over-the-counter preparations for hemorrhoids
• B. Place the client in a standing position, leaning over the exam bed for inspection
• C. Position the client in the left lateral position to inspect the perineal area for fissures or sacs
• D. Ask the client how long she has experienced discomfort related to hemorrhoids

Correct answer: D

Rationale: Asking the client about the duration of discomfort related to hemorrhoids is the best intervention to implement for a focused assessment. This information provides important context for assessing the severity and chronicity of the condition, which is crucial for developing an appropriate care plan. Choices A, B, and C do not directly address the need to gather information about the duration of symptoms, which is essential for understanding the client's condition.

3. Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

• A. Withhold the medication and notify the charge nurse
• B. Give the medication and document the heart rate
• C. Withhold the medication until the next scheduled dose
• D. Request the charge nurse to administer the medication

Correct answer: B

Rationale: A heart rate of 120 beats per minute is within the normal range for a 2-month-old infant. Therefore, it is safe to administer the digoxin and document the heart rate as part of routine care. Choice A is incorrect as withholding the medication is not necessary since the heart rate is normal. Choice C is incorrect as there is no need to delay the administration until the next scheduled dose when the heart rate is within the normal range. Choice D is incorrect as the primary nurse is not needed to administer the medication since the heart rate is normal and falls within the safe range for administration.

4. What is the most common sign of a localized infection?

• A. Fever
• B. Elevated white blood cell count
• C. Redness, warmth, and swelling at the site of infection
• D. Chills and shivering

Correct answer: C

Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice B) can be seen in both localized and systemic infections. Chills and shivering (choice D) are more related to the body's response to fever and not specifically indicative of a localized infection.

5. After administering pantoprazole to a client with gastroesophageal reflux disease (GERD), which statement by the client indicates to the nurse that the medication is producing the desired effect?

• A. After eating my meal, I did not experience any heartburn
• B. I have a great appetite and am feeling really hungry
• C. I should increase the amount of vitamin C in my diet
• D. While eating, I had no difficulty swallowing any of the foods

Correct answer: A

Rationale: The correct answer is A. Pantoprazole reduces stomach acid production, thus preventing the occurrence of heartburn after meals, which is a common symptom of GERD. Choice B is incorrect because an increased appetite and hunger are not indicators of the desired effect of pantoprazole. Choice C is unrelated to the medication's effect on GERD symptoms. Choice D is also incorrect because the absence of difficulty swallowing is not a specific indicator of pantoprazole's effectiveness in treating GERD.

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