Nursing Elites

1. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

• A. Apply a pressure dressing around the chest tube site.
• B. Administer an oral antihistamine.
• C. Assess for allergies to topical cleaning agents.
• D. Measure the area of swelling and crackling.

Correct answer: D

Rationale: When a nurse observes crepitus around a chest tube site, it could indicate subcutaneous emphysema, a potentially serious condition where air gets trapped under the skin. Measuring the area of swelling and crackling is important as it helps monitor the progression of subcutaneous emphysema. Applying a pressure dressing (choice A) might not address the underlying cause and could potentially worsen the condition. Administering an oral antihistamine (choice B) is not indicated for crepitus at a chest tube site. Assessing for allergies to topical cleaning agents (choice C) is important but not the immediate priority when crepitus is observed.

2. The healthcare provider prescribes celtazidime for an infant, IM, every 8 hours. The vial is 500 mg with a concentration of 100 mg/ml after reconstitution. How many ml should the nurse administer?

• A. 3 ml.
• B. 0.4 ml.
• C. 1.2 ml.
• D. 0.9 ml.

Correct answer: B

Rationale: To administer 35 mg of celtazidime from a 100 mg/ml solution, the nurse should give 0.4 ml of the reconstituted celtazidime solution. The calculation is 35 mg / 100 mg/ml = 0.35 ml, but since the vial is 500 mg, the answer is 0.35 ml * (500 mg / 100 mg) = 0.4 ml. Therefore, choices A, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

3. A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?

• A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest
• B. Visual problems are unrelated to the recent immunizations
• C. Increase fluid intake to reduce symptoms of fatigue
• D. Consult the healthcare provider immediately for steroid therapy

Correct answer: A

Rationale: Immunizations can sometimes trigger relapses in multiple sclerosis due to the activation of the immune system. Extra rest can help manage these symptoms. Choice B is incorrect because visual problems can be associated with the immune response triggered by immunizations in individuals with multiple sclerosis. While increasing fluid intake is generally good advice, in this case, the nurse should focus on explaining the possible connection between the immunizations and the symptoms experienced. Choice D is not the immediate course of action; educating the patient on the potential link between immunizations and symptom exacerbation is more appropriate at this stage.

4. In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?

• A. Pulse oximetry
• B. Blood glucose
• C. Arterial blood gases
• D. Serum electrolytes

Correct answer: B

Rationale: Deep, rapid respirations (Kussmaul respirations) and lethargy are signs of diabetic ketoacidosis (DKA), which occurs in uncontrolled type 1 diabetes. Checking the blood glucose is the priority to confirm hyperglycemia and guide immediate treatment. Pulse oximetry is not the priority in this situation as the issue is related to altered glucose levels, not oxygenation. Arterial blood gases and serum electrolytes may be important later in the management of DKA but are not the initial priority compared to confirming and addressing the hyperglycemia.

5. What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?

• A. Monitor for signs of infection.
• B. Measure abdominal girth and monitor for pain.
• C. Check for bowel movement and changes in stool.
• D. Assess hydration status and monitor urine output.

Correct answer: C

Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.

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