Nursing Elites

1. Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client’s dressing. Which additional assessment finding warrants immediate intervention by the nurse?

• A. Sore throat when swallowing
• B. Tongue deviation to the left
• C. Palpable temporal pulses
• D. Temperature of 99.2°F (37.3°C)

Correct answer: B

Rationale: Tongue deviation to the left is the correct answer. It could indicate a complication such as nerve injury or hematoma, which requires immediate attention. A sore throat when swallowing may be expected postoperatively but does not indicate an immediate complication. Palpable temporal pulses are a normal finding and do not require immediate intervention. A temperature of 99.2°F (37.3°C) is slightly elevated but does not suggest a critical issue related to the surgery.

2. Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?

• A. Place a pulse oximeter on the heel
• B. Swaddle the infant in a warm blanket
• C. Record the findings on the flow sheet
• D. Check the vital signs in 15 minutes

Correct answer: C

Rationale: The correct action for the nurse to take in this scenario is to record the findings on the flow sheet. The newborn's axillary temperature, heart rate, and respiratory rate are within normal limits for a 3-hour-old newborn. Therefore, there is no immediate need for intervention or further assessment. Swaddling the infant in a warm blanket, placing a pulse oximeter on the heel, or checking the vital signs in 15 minutes are not necessary actions based on the normal assessment findings presented. These actions could potentially disrupt the newborn or lead to unnecessary interventions when the baby is stable.

3. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion, and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?

• A. Restrict daily fluid intake
• B. Eat meals at the same time daily
• C. Maintain a low-protein diet
• D. Limit the intake of high-calorie foods

Correct answer: A

Rationale: Dependent edema in both lower legs is a sign of fluid overload, which can exacerbate dyspnea in patients with COPD. Restricting daily fluid intake can help reduce the edema and alleviate breathing difficulties. A low-protein diet is not necessary unless there are specific renal concerns. Eating meals at the same time daily or limiting high-calorie foods is not directly associated with addressing fluid overload and dyspnea in COPD patients.

4. A client with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24-hour period? (Enter a numeric value only. If rounding is required, round to the nearest tenth)

• A. 4.5
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the total dose of baclofen needed in a 24-hour period, multiply 15 mg by 3 doses, which equals 45 mg. Since the tablets are available in 10 mg strength, divide the total dose needed (45 mg) by the strength of each tablet (10 mg), which equals 4.5 tablets. Rounding off to the nearest tenth, the nurse should administer 4.5 tablets of 10 mg baclofen per day. Therefore, choice A is correct. Choices B, C, and D are irrelevant as they are not provided.

5. When educating a group of school-age children on reducing the risk of Lyme disease, which instruction should the camp nurse include?

• A. Wash hands frequently
• B. Avoid drinking lake water
• C. Wear long sleeves and pants
• D. Do not share personal products

Correct answer: C

Rationale: The correct instruction to reduce the risk of Lyme disease is to wear long sleeves and pants. This helps prevent tick bites, which are the primary mode of transmission for Lyme disease. Wearing protective clothing reduces the skin's exposure to ticks, decreasing the chances of getting bitten. Washing hands frequently (Choice A) is important for general hygiene but not specifically for preventing Lyme disease. Avoiding drinking lake water (Choice B) is unrelated to the prevention of Lyme disease. Not sharing personal products (Choice D) is important for preventing the spread of infections but does not directly reduce the risk of Lyme disease.

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