Nursing Elites

1. When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?

• A. Cancer of any type
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium in older adults is commonly caused by medication side effects or interactions. Investigating prescription drug intoxication is crucial as it can be a reversible cause of delirium. While cancer, impaired hearing, and heart failure are important considerations in overall care, prescription drug intoxication takes precedence in cases of delirium.

2. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

• A. WBC count 2,900 /mm3.
• B. Fasting blood glucose 100 mg/dl.
• C. Hgb 14 g/dl.
• D. Heart rate 58/min.

Correct answer: A

Rationale: A WBC count of 2,900/mm3 indicates leukopenia, which is a serious side effect of clozapine and contraindicates its use. Leukopenia is a significant concern with clozapine therapy due to the risk of agranulocytosis, a potentially life-threatening condition. Monitoring the WBC count is crucial to detect this adverse effect early. The other options (B, C, and D) are within normal ranges and not contraindications for administering clozapine.

3. A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

• A. Ensure the injection produces a wheal on the skin
• B. Administer the injection in the client's thigh
• C. Use an intradermal needle for the injection
• D. Avoid touching the site after injection

Correct answer: A

Rationale: The correct answer is A: Ensure the injection produces a wheal on the skin. A wheal indicates that the PPD has been administered correctly, allowing for the proper interpretation of results. Administering the injection in the client's thigh (choice B) is not the recommended site for PPD administration; it should be administered intradermally. Using an 18-gauge needle (choice C) is unnecessary and not the standard practice for PPD administration as a smaller gauge needle is preferred for intradermal injections. Massaging the site after injection (choice D) can lead to inaccurate results by dispersing the solution, so it is important to avoid touching the site after the injection to prevent altering the test results.

4. A healthcare professional is collecting data from a client who has iron deficiency anemia. Which of the following findings should the healthcare professional expect?

• A. Increased energy
• B. Easy bruising
• C. Pale conjunctiva
• D. Weight gain

Correct answer: C

Rationale: Pale conjunctiva is a common sign of iron deficiency anemia due to reduced hemoglobin levels. This results in decreased oxygen-carrying capacity, leading to tissue hypoxia and pallor. 'Increased energy' (choice A) is not typically associated with iron deficiency anemia, as fatigue and weakness are common symptoms. 'Easy bruising' (choice B) is more characteristic of platelet disorders or vitamin deficiencies rather than iron deficiency anemia. 'Weight gain' (choice D) is not a typical finding in iron deficiency anemia; in fact, weight loss is more common due to decreased appetite and overall weakness.

5. A nurse is caring for a client who is in the early stages of hypovolemic shock. Which of the following findings should the nurse expect?

• A. Heart rate 60/min
• B. Increased urinary output
• C. Increased respiratory rate
• D. Hypothermia

Correct answer: C

Rationale: In the early stages of hypovolemic shock, the body initiates compensatory mechanisms to maintain perfusion. One of these mechanisms is an increased respiratory rate to improve oxygen delivery. This helps to offset the decreased circulating blood volume. A heart rate of 60/min (choice A) is not expected in hypovolemic shock; instead, tachycardia is a common finding due to the body's attempt to maintain cardiac output. Increased urinary output (choice B) is not typically seen in hypovolemic shock as the body tries to conserve fluid. Hypothermia (choice D) is usually a late sign of shock when the body's compensatory mechanisms are failing, and perfusion is severely compromised.

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