Nursing Elites

1. Which of the following medications should be held 24-48 hours prior to an electroencephalogram (EEG)?

• A. Lasix (furosemide)
• B. Cardizem (diltiazem)
• C. Lanoxin (digoxin)
• D. Dilantin (phenytoin)

Correct answer: D

Rationale: Anticonvulsants like Dilantin should be held 24-48 hours before an EEG to prevent interference with the test results. Medications such as tranquilizers, barbiturates, and other sedatives should also be avoided. Lasix, Cardizem, and Lanoxin do not belong to these categories and are not known to interfere with EEG results.

2. What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

• A. Place the client in isolation until further assessment is completed.
• B. Seclude the client from other clients and visitors.
• C. Perform no intervention until test results confirm a diagnosis.
• D. Don personal protective equipment immediately.

Correct answer: B

Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.

3. Where do the vast majority of deaths resulting from unintentional poisoning occur?

• A. Infants
• B. Toddlers
• C. Teens
• D. Adults

Correct answer: B

Rationale: The correct answer is 'Toddlers.' Toddlers are at the highest risk of unintentional poisoning due to their natural curiosity, explorative behavior, and lack of awareness of potential dangers. Infants are typically closely monitored, teens are more aware of risks, and adults generally have better judgment and understanding of hazardous substances, making them less susceptible to unintentional poisoning. Therefore, toddlers, being inquisitive and unaware of risks, are the most vulnerable group in terms of unintentional poisoning incidents.

4. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

• A. Ask the nursing assistant to complete an incident report
• B. Check the client's level of consciousness and vital signs
• C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
• D. Ask the nursing assistant to assist in getting the client back to bed

Correct answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.

5. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

• A. Increase maternal fluids.
• B. Administer oxygen.
• C. Decrease maternal fluids.
• D. Turn the mother.

Correct answer: C

Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.

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