Nursing Elites

1. Melissa Smith came to the Emergency Department in the last week before her estimated date of confinement complaining of headaches, blurred vision, and vomiting. Suspecting PIH, the nurse should best respond to Melissa's complaints with which of the following statements?

• A. "The physician will probably want to admit you for observation."?
• B. "The physician will probably order bedrest at home."?
• C. "These are really dangerous signs."?
• D. "The physician will probably prescribe some medicine for you."?

Correct answer: B

Rationale: Pregnancy-induced hypertension (PIH) is a hypertensive disorder of pregnancy that can present after 20 weeks gestation. It is characterized by symptoms like edema, hypertension, and proteinuria, which can progress to conditions like pre-eclampsia and eclampsia. The best approach for a client with advanced PIH is rest, and home provides the most suitable environment for it. Hospitalization is not typically necessary for PIH unless there are severe complications. Medication alone is not the primary intervention for PIH; management often involves monitoring, rest, and close medical supervision. Therefore, advising bedrest at home is the most appropriate response to help manage PIH symptoms and prevent further complications, such as pre-eclampsia or eclampsia. The other options, like hospitalization for observation, emphasizing the danger of the signs without providing guidance, or assuming medication as the primary solution, are not in line with the standard management approach for PIH.

2. What is the best position for a client immediately following a bilateral salpingooophorectomy?

• A. Fowler's
• B. Modified Sims
• C. Side lying
• D. Flat supine

Correct answer: C

Rationale: The best position for a client immediately following a bilateral salpingooophorectomy is side lying. This position promotes comfort with the knees flexed and ensures proper airway management. Fowler's position (Choice A) would not be ideal as it involves sitting at a 90-degree angle, potentially causing discomfort after this procedure. Modified Sims position (Choice B) is typically used for rectal examinations, not for post-surgical management. Flat supine (Choice D) may not be the best choice immediately after surgery as it does not provide the same level of comfort and airway protection as side lying with knees flexed.

3. Which of the following diseases or conditions is least likely to be associated with an increased potential for bleeding?

• A. metastatic liver cancer
• B. gram-negative septicemia
• C. pernicious anemia
• D. iron-deficiency anemia

Correct answer: C

Rationale: Pernicious anemia is least likely to be associated with an increased potential for bleeding compared to the other conditions listed. Pernicious anemia is a condition resulting from vitamin B12 deficiency due to the absence of intrinsic factor, necessary for B12 absorption. While pernicious anemia can lead to neurological issues, it is not directly linked to an increased risk of bleeding. Metastatic liver cancer can cause liver dysfunction leading to coagulopathy, gram-negative septicemia can result in disseminated intravascular coagulation (DIC), and iron-deficiency anemia can lead to microcytic hypochromic red blood cells, increasing the risk of bleeding. Therefore, pernicious anemia is the least likely to be associated with an increased potential for bleeding out of the options provided.

4. Which physiologic mechanism best describes the function of the sodium-potassium pump?

• A. active transport
• B. diffusion
• C. filtration
• D. osmosis

Correct answer: A

Rationale: Active transport is the correct answer as it accurately describes the process involved in the sodium-potassium pump. The pump utilizes energy to move ions against their concentration gradient, maintaining cellular concentrations. Diffusion (choice B) is a passive process where substances move from an area of higher concentration to lower concentration. Filtration (choice C) involves the movement of solutes based on pressure gradients. Osmosis (choice D) is the movement of water across a semipermeable membrane.

5. After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?

• A. Gently rub the injection site after removing the needle
• B. Have the client maintain a side-lying position for at least five minutes
• C. Remove the needle and engage the needle safety device
• D. Apply heat to the injection site

Correct answer: C

Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.

Similar Questions