Nursing Elites

1. A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?

• A. Call the surgeon immediately.
• B. Administer Extra Strength Tylenol per orders.
• C. Assess the surgical site.
• D. Offer extra blankets and increase fluids.

Correct answer: A

Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4°F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.

2. Which of the following injuries, presented by a client entering the Emergency Department, is the highest priority?

• A. open leg fracture
• B. open head injury
• C. stab wound to the chest
• D. traumatic amputation of a thumb

Correct answer: C

Rationale: A stab wound to the chest is the highest priority injury. This type of injury can lead to lung collapse and mediastinal shift, potentially resulting in death if left untreated. Treating an obstructed airway or a chest wound takes precedence over addressing hemorrhage. The principle of ABC (airway, breathing, and circulation) guides care decisions in prioritizing life-threatening situations. An open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate threat to life compared to a stab wound to the chest. An open leg fracture may lead to significant blood loss but is not immediately life-threatening. An open head injury requires assessment and intervention but does not impact airway, breathing, or circulation directly. Traumatic amputation of a thumb is a serious injury but can be managed after addressing more life-threatening conditions.

3. Which statement best describes electrolytes in intracellular and extracellular fluid?

• A. There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid
• B. There is an equal concentration of sodium and potassium in extracellular fluid
• C. There is a greater concentration of potassium in extracellular fluid and sodium in intracellular fluid
• D. There is an equal concentration of sodium and potassium between intracellular and extracellular fluid

Correct answer: A

Rationale: Electrolytes are distributed unequally between intracellular and extracellular fluids. Sodium concentration is higher in extracellular fluid, while potassium concentration is higher in intracellular fluid. Therefore, the correct answer is 'There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid.' Choices B, C, and D are incorrect because they do not accurately describe the typical distribution of sodium and potassium between intracellular and extracellular fluid.

4. A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?

• A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.
• B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.
• C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.
• D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus

Correct answer: B

Rationale: The correct answer is: 'Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.' Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD). Choice A is incorrect because emphysema is not primarily characterized by hyperactivity of the medium-sized bronchi causing wheezing and tightness in the chest. Choice C is incorrect because vasodilation, congestion, and mucosal edema are not the primary mechanisms involved in emphysema, and they do not directly lead to chronic cough and sputum production. Choice D is incorrect because emphysema is not related to chloride transport issues and thick viscous mucus production.

5. A patient has been admitted to the hospital with an L4-5 HNP diagnosis. After 24 hours, the patient is able to ambulate with assistance and has reduced muscle spasms. Which of the following medications was the most beneficial in changing the patient's mobility status?

• A. Mivacron
• B. Atropine
• C. Bethanechol
• D. Flexeril

Correct answer: D

Rationale: The correct answer is Flexeril. Flexeril is a muscle relaxant commonly used to treat acute muscle pain and spasms. In this scenario, the patient experiencing reduced muscle spasms and improved mobility after taking Flexeril indicates its effectiveness. Choice A, Mivacron, is a neuromuscular blocking agent that is not typically used for muscle spasms or pain relief. Choice B, Atropine, is a medication used to treat certain types of nerve agent and pesticide poisonings, not muscle spasms. Choice C, Bethanechol, is a medication that stimulates bladder contractions and is not indicated for muscle spasms or mobility improvement.

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