Nursing Elites

1. The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. What action should the nurse take next?

• A. Auscultate anterior and posterior breath sounds bilaterally
• B. Encourage the patient to turn, cough, and deep breathe
• C. Review the chest x-ray report for evidence of pneumonia
• D. Palpate the anterior chest and observe for barrel chest

Correct answer: A

Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99'. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with conditions like pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Encouraging the patient to turn, cough, and deep breathe is an appropriate intervention for atelectasis, but assessing breath sounds takes priority. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). Palpating the anterior chest for fremitus is less effective due to the presence of large muscles and breast tissue, making auscultation a more appropriate next step.

2. Which laboratory test result should the nurse monitor to evaluate the effects of therapy for a 62-year-old female patient with acute pancreatitis?

• A. Calcium
• B. Bilirubin
• C. Amylase
• D. Potassium

Correct answer: C

Rationale: The correct answer is C: Amylase. In acute pancreatitis, amylase levels are typically elevated. Monitoring amylase levels helps assess the effectiveness of therapy in managing the condition. Elevated amylase is a key indicator of pancreatic inflammation. Calcium (Choice A) levels may be affected in pancreatitis, but they are not the primary indicator for evaluating therapy effectiveness. Bilirubin (Choice B) and Potassium (Choice D) levels may also be altered in pancreatitis, but they are not specific markers for monitoring therapy response in acute pancreatitis.

3. A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:

• A. Hypotriglyceridemia
• B. Abdominal hernia
• C. Anorexia
• D. Peritonitis

Correct answer: A

Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.

4. A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?

• A. Fear
• B. Helplessness
• C. Self-blame
• D. Rejection

Correct answer: C

Rationale: The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (Choice A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (Choice B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (Choice D) does not accurately reflect the victim's statement and emotional response in the given scenario.

5. The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

• A. Diarrhea
• B. Projectile vomiting
• C. Regurgitation of feedings
• D. Constipation

Correct answer: C

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is characterized by the absence of ganglion cells in the rectum and other parts of the affected intestine. Clinical manifestations of Hirschsprung's disease include chronic constipation with pellet-like or ribbon-like foul-smelling stools, delayed or absent passage of meconium in the neonatal period, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive. In the case of an infant with suspected Hirschsprung's disease, regurgitation of feedings is a sign that may have led the mother to seek healthcare. This symptom can be associated with the bowel dysfunction and obstruction seen in Hirschsprung's disease. Options A, B, and D are not typically associated with Hirschsprung's disease. Diarrhea is not a common symptom, projectile vomiting is not a typical presentation, and constipation, while a symptom of the disease, is not the sign that would most likely prompt a visit to seek healthcare in an infant suspected of having Hirschsprung's disease.

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