Nursing Elites

1. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?

• A. Bowel sounds are present.
• B. Grey Turner sign resolves.
• C. Electrolyte levels are normal.
• D. Abdominal pain is decreased.

Correct answer: D

Rationale: The correct answer is 'Abdominal pain is decreased.' In a patient with acute pancreatitis, the goal of using an NG tube for suction and keeping the patient NPO is to decrease the release of pancreatic enzymes and alleviate pain. Therefore, a decrease in abdominal pain would indicate the effectiveness of these therapies. Bowel sounds being present do not necessarily indicate treatment effectiveness, as they can still be present even if the therapies are not fully effective. Normal electrolyte levels are important but do not directly reflect the efficacy of NG suction and NPO status. The resolution of Grey Turner sign, a bruising over the flanks associated with pancreatitis, is a late and non-specific finding and waiting for it to resolve is not a reliable indicator of treatment effectiveness.

2. A 33-year-old male client with heart failure has been taking furosemide for the past week. Which of the following assessment cues below may indicate the client is experiencing a negative side effect from the medication?

• A. Weight gain of 5 pounds
• B. Edema of the ankles
• C. Gastric irritability
• D. Decreased appetite

Correct answer: D

Rationale: The correct answer is 'Decreased appetite.' Furosemide is a loop diuretic used for conditions like heart failure, where it helps reduce fluid retention. One common side effect of furosemide is hypokalemia, which can lead to decreased appetite among other symptoms. Hypokalemia is a low level of potassium in the blood, and its signs and symptoms include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, and altered level of consciousness. Weight gain and ankle edema are actually expected outcomes of furosemide therapy due to its diuretic effect, which helps reduce edema and fluid overload. Gastric irritability is a nonspecific symptom that is not typically associated with furosemide use. Therefore, a decreased appetite is a key indicator of a potential negative side effect when assessing a client on furosemide therapy.

3. When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should

• A. assess for the presence of chest pain.
• B. inquire about urinary tract problems.
• C. inspect the skin for rashes or discoloration.
• D. ask the patient about any increase in libido.

Correct answer: B

Rationale: When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.

4. A patient is on bedrest 24 hours after a hip fracture. Which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?

• A. Performing passive, light range-of-motion exercises on the hip as tolerated.
• B. Assess the patient's mental status for drowsiness or sleepiness.
• C. Assess the pedal pulse and capillary refill in the toes.
• D. Administer a stool softener as ordered.

Correct answer: B

Rationale: In detecting or preventing Fat Embolism Syndrome (FES), assessing the patient's mental status for drowsiness or sleepiness is crucial. Decreased level of consciousness is an early sign of FES due to decreased oxygen levels. Performing passive, light range-of-motion exercises on the hip may not directly relate to FES. Assessing pedal pulse and capillary refill in the toes is essential for assessing circulation but not specific to detecting FES. Administering a stool softener, while important for preventing constipation in immobilized patients, is not directly related to detecting or preventing FES.

5. A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?

• A. Assess the patient for nuchal rigidity
• B. Determine the patient's past exposure to infectious organisms
• C. Check the patient's WBC lab values
• D. Monitor for increased lethargy and drowsiness

Correct answer: D

Rationale: Monitoring for increased lethargy and drowsiness is crucial as these symptoms indicate a decreased level of consciousness, which is the cardinal sign of increased Intracranial Pressure (ICP). Elevated ICP can lead to serious complications and requires immediate intervention. Assessing for nuchal rigidity is important in suspected cases of meningitis but monitoring lethargy and drowsiness takes precedence due to its direct correlation with ICP. Determining past exposure to infectious organisms and checking WBC lab values are important for diagnosing and treating meningitis but do not directly address the immediate concern of increased ICP.

Similar Questions