Nursing Elites

1. What is the appropriate action when a patient experiences an allergic reaction to a medication?

• A. Administer epinephrine
• B. Discontinue the medication
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for a severe allergic reaction as it helps to constrict blood vessels, increase heart rate, and open airways, thereby improving breathing and circulation. Discontinuing the medication may not be sufficient to manage a severe allergic reaction as the allergen is already in the patient's system. Corticosteroids and antihistamines can be considered as complementary treatments but are not the primary immediate intervention required for a severe allergic reaction.

2. A nurse is assessing a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lipsmacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lipsmacking is a common sign of tardive dyskinesia, a long-term side effect of haloperidol. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements such as lipsmacking, tongue protrusion, and facial grimacing. Agranulocytosis (choice B) is a potential side effect of antipsychotic medications but is not specifically associated with haloperidol. Clang association (choice C) is a form of disorganized speech seen in conditions like schizophrenia but is not a side effect of haloperidol. Alopecia (choice D) refers to hair loss and is not a common long-term side effect of haloperidol.

3. A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Apply cold compresses to the affected extremity.
• B. Massage the affected extremity every 2 hours.
• C. Elevate the affected extremity above the level of the heart.
• D. Keep the affected extremity dependent when sitting.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.

4. A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the provider?

• A. Constant bubbling in the water seal chamber.
• B. Intermittent bubbling in the suction control chamber.
• C. Tidaling in the water seal chamber.
• D. Drainage of 75 mL in the first 24 hours.

Correct answer: A

Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.

5. How should a healthcare professional monitor a patient on furosemide for fluid balance?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor input and output
• D. Monitor blood pressure

Correct answer: A

Rationale: Monitoring a patient's daily weight is crucial when assessing fluid balance in individuals prescribed furosemide. Furosemide is a diuretic that helps the body eliminate excess fluid and salt. Changes in weight can reflect fluid shifts, making daily weight monitoring a reliable indicator of fluid status. While checking for edema and monitoring input and output are essential aspects of fluid balance assessment, they may not provide as immediate and quantifiable information as daily weight measurements. Monitoring blood pressure is important in patients on furosemide due to its potential to affect blood pressure levels, but it is not as directly indicative of fluid balance as daily weight monitoring.

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