Nursing Elites

1. Which intervention should the nurse include in the plan of care for a patient with tetanus?

• A. Open window shades to provide natural light
• B. Encourage coughing and deep breathing
• C. Minimize the amount of stimuli in the room
• D. Reposition from side to side every hour

Correct answer: C

Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (Choice A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (Choice B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (Choice D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.

2. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned, and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the nurse notes late decelerations during contractions despite repositioning and oxygen administration. Late decelerations are often associated with uteroplacental insufficiency, which can be exacerbated by increased uterine activity stimulated by oxytocin. The initial action to manage late decelerations is to turn off the oxytocin infusion to reduce uterine stimulation. This step aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth may be necessary if the late decelerations persist or worsen despite discontinuing the oxytocin infusion. Notifying the anesthesiologist to disconnect the epidural infusion or applying an internal fetal monitoring device are not the first-line interventions for managing late decelerations.

3. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?

• A. Usual and current weight
• B. Color and amount of urine
• C. Number and frequency of stools
• D. Intake and output 24 hours prior to admission

Correct answer: A

Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.

4. A client is admitted with pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?

• A. Tissue sloughing upon extravasation
• B. Elevated blood pressure and heart rate
• C. Tinnitus and vertigo
• D. Erythema of the face, neck, and chest

Correct answer: C

Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.

5. A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse’s assessment reveals an elevated blood pressure. Which intervention should the nurse implement first?

• A. Encourage the client to see a dermatologist
• B. Refer the adolescent to a substance abuse program
• C. Suggest a low-salt, low-fat, and caffeine-free diet
• D. Inquire about a possible use of anabolic steroids

Correct answer: D

Rationale: In this scenario, the high school football player presenting with severe acne, behavior changes, elevated blood pressure, and suspicion of friends suggests the possible use of anabolic steroids. Anabolic steroid use can lead to such symptoms. Therefore, the nurse should first inquire about the possible use of anabolic steroids to address the root cause of the presenting issues. Encouraging the client to see a dermatologist (Choice A) may be necessary but addressing the underlying cause is crucial first. Referring the adolescent to a substance abuse program (Choice B) is premature without confirming steroid use. Suggesting a low-salt, low-fat, and caffeine-free diet (Choice C) is not the priority in this situation where a serious issue like anabolic steroid use needs immediate attention.

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