Nursing Elites

1. In which order should the nurse take the following actions for an older patient with new onset confusion who is normally alert and oriented?

• A. Obtain the oxygen saturation, Check the patient's pulse rate, Notify the health care provider, Document the change in status
• B. Obtain the oxygen saturation, Check the patient's pulse rate, Document the change in status, Notify the health care provider
• C. Document the change in status, Notify the health care provider, Check the patient's pulse rate, Obtain the oxygen saturation
• D. Document the change in status, Check the patient's pulse rate, Obtain the oxygen saturation, Notify the health care provider

Correct answer: B

Rationale: The correct order of actions for the nurse in this scenario is to first obtain the oxygen saturation to assess the patient's airway and oxygenation status. Next, checking the patient's pulse rate helps in evaluating circulation. Subsequently, documenting the change in the patient's status is important for maintaining an accurate record of care. Finally, notifying the health care provider is crucial to ensure timely intervention and further management. Choices A, C, and D are incorrect because assessing oxygen saturation should precede checking the pulse rate to address potential physiological causes of confusion. Additionally, documentation should follow patient assessment and notification of the healthcare provider for appropriate record-keeping and communication.

2. Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

• A. Teach about symptoms of variceal bleeding
• B. Draw blood for hepatitis serology testing
• C. Discuss the need to increase caloric intake
• D. Review the patient's current medication list

Correct answer: D

Rationale: The correct action for a patient diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD) would be to review the patient's current medication list. This is important because certain medications can increase the risk for NAFLD, and they should be identified and possibly eliminated. Teaching about symptoms of variceal bleeding is not necessary as variceal bleeding is not a concern in a patient with asymptomatic NAFLD. Drawing blood for hepatitis serology testing is not indicated as NAFLD is not associated with hepatitis. Discussing the need to increase caloric intake is also not appropriate since weight loss is usually recommended in the management of NAFLD.

3. A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient's lab results would expect which of the following changes in laboratory findings?

• A. Elevated serum calcium
• B. Low serum parathyroid hormone (PTH)
• C. Elevated serum vitamin D
• D. Low urine calcium

Correct answer: A

Rationale: In primary hyperparathyroidism, there is excess secretion of parathyroid hormone (PTH) leading to increased resorption of calcium from bones and decreased excretion of calcium by the kidneys. This results in elevated serum calcium levels. Elevated serum calcium is a hallmark characteristic of primary hyperparathyroidism, making it the correct answer. Low serum parathyroid hormone (PTH) (Choice B) is incorrect because primary hyperparathyroidism is associated with elevated PTH levels due to the malfunction of the parathyroid glands. Elevated serum vitamin D (Choice C) is incorrect because primary hyperparathyroidism is not typically associated with elevated vitamin D levels. Low urine calcium (Choice D) is incorrect as primary hyperparathyroidism leads to decreased calcium excretion by the kidneys, resulting in high levels of calcium in the urine.

4. A patient with Glaucoma is verbalizing his daily medication routine to the nurse. He states he has two different eye drop medications, both every twelve hours. He washes his hands, instills the drops, closes his eyes gently, and presses his finger to the corner of his eye nearest his nose. After waiting 1 minute with his eyes closed, he instills the other medication in the same way. What is the nurse's best response?

• A. ''You should wait more than 1 minute between different medications.''
• B. ''Your routine is very good! Can you demonstrate it for me?''
• C. ''It is actually not the best practice to close your eyes after instilling eye drops.''
• D. ''You should actually be pressing your finger in the other corner of the eye.''

Correct answer: A

Rationale: It is recommended to wait 10-15 minutes between different eye drop medications to give them time to absorb and avoid one medication washing another one out. Choice A is the correct response as the patient should wait more than 1 minute between administering different eye drop medications. Choice B is incorrect as the routine described by the patient needs improvement. Choice C is inaccurate as closing the eyes after instilling eye drops is a best practice to ensure proper absorption. Choice D is incorrect as pressing the finger to the corner of the eye nearest the nose is the correct technique.

5. When assessing a child admitted to the hospital with pyloric stenosis, which symptom would the nurse likely find when asking the parent about the child's symptoms?

• A. Watery diarrhea
• B. Projectile vomiting
• C. Increased urine output
• D. Vomiting large amounts of bile

Correct answer: B

Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. The hallmark symptom of pyloric stenosis is projectile vomiting, which is the forceful expulsion of stomach contents. Other common symptoms include irritability, hunger and crying, constipation, and signs of dehydration. Watery diarrhea (Choice A) is not a typical symptom of pyloric stenosis. Increased urine output (Choice C) is not directly associated with this condition. Vomiting large amounts of bile (Choice D) is not a characteristic symptom of pyloric stenosis; instead, the vomitus in pyloric stenosis is non-bilious.

Similar Questions