Nursing Elites

1. A client is brought into the emergency department after finishing a course of antibiotics for a urinary tract infection. The client is experiencing dyspnea, chest tightness, and agitation. Her blood pressure is 88/58, she has generalized hives over her body, and her lips and tongue are swollen. After the nurse calls for help, what is the next appropriate action?

• A. Start an IV and administer a 1-liter bolus of Lactated Ringer's solution
• B. Administer 0.3 mg of 1:1000 epinephrine IM
• C. Administer 15 mg diphenhydramine IM
• D. Monitor the client until help arrives

Correct answer: B

Rationale: A client experiencing an anaphylactic reaction will likely present with rash or hives, swelling of the lips, face, or tongue, hypotension, or dyspnea. In this scenario, the client is showing signs of anaphylaxis with dyspnea, chest tightness, hives, hypotension, and swelling of the lips and tongue. The next appropriate action would be to administer 0.3 mg of 1:1000 epinephrine intramuscularly. Epinephrine helps relax the muscles of the airway, improve breathing, and increase oxygenation, which is crucial in managing anaphylaxis. Starting an IV and administering fluids can be important but not the immediate priority. Diphenhydramine may be used as an adjunct therapy but should not delay the administration of epinephrine in the acute phase of anaphylaxis. Monitoring the client without providing immediate treatment can lead to a worsening of the anaphylactic reaction, potentially resulting in a life-threatening situation.

2. A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?

• A. The patient will be admitted to the medicine unit for observation and medication.
• B. The patient will be admitted to the day surgery unit for sclerotherapy.
• C. The patient will be admitted to the surgical unit and resection will be scheduled.
• D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.

Correct answer: C

Rationale: A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.

3. Which client is at highest risk for developing a pressure ulcer?

• A. 23 year-old in traction for fractured femur
• B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
• C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
• D. 30 year-old who is comatose following a ruptured aneurysm

Correct answer: C

Rationale: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

4. In a 24-year-old woman, the term used to define uterine bleeding in which there is no menstruation is:

• A. Oligomenorrhea
• B. Amenorrhea
• C. Menorrhagia
• D. Metrorrhagia

Correct answer: B

Rationale: Amenorrhea is the correct term for the absence of menstrual periods in a woman of childbearing age. It is typically defined as no menstruation for at least three consecutive cycles or six months. Oligomenorrhea refers to infrequent or irregular menstrual periods rather than complete absence. Menorrhagia is characterized by excessive menstrual bleeding, not the absence of menstruation. Metrorrhagia involves irregular, acyclic bleeding between menstrual periods, which is different from the absence of menstruation.

5. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?

• A. Teach about the reason for the blood tests.
• B. Schedule an appointment for a chest x-ray.
• C. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
• D. Instruct the patient to expectorate three specimens as soon as possible.

Correct answer: C

Rationale: The correct action for the nurse to take is to teach the patient about the need to collect sputum specimens for 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. It is important to obtain these specimens on different days rather than all at once. Blood tests are not used for tuberculosis testing, so teaching about blood tests is not relevant. While a chest x-ray is important in tuberculosis diagnosis, it is not a bacteriologic test. The appearance on a chest x-ray alone is not sufficient to diagnose TB as other diseases can have similar findings.

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