Nursing Elites

1. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication?

• A. Increased urinary clearance of the multiple medications has led to diuresis and lowered the blood pressure.
• B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness.
• C. The additive effect of multiple medications has caused the blood pressure to drop too low.
• D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.

Correct answer: C

Rationale: The correct answer is C. When a client experiences syncope due to a significant drop in blood pressure after receiving multiple antihypertensive medications, the additive effect of these medications can cause the blood pressure to drop excessively. This additive effect can lead to hypotension, which is why the nurse decided to hold the client's scheduled antihypertensive medication. Choices A, B, and D provide incorrect rationales. Choice A mentions diuresis, which is not directly related to the drop in blood pressure due to additive medication effects. Choice B refers to an antagonistic interaction reducing effectiveness, which is not applicable in this scenario. Choice D talks about a synergistic effect leading to drug toxicity, which is not the cause of the sudden drop in blood pressure observed in the client.

2. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?

• A. Thrombocytopenia
• B. Polycythemia
• C. Decreased ESR
• D. Positive ASO titer

Correct answer: D

Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.

3. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.

• A. Observe for an intradermal bleed after the antigen is injected
• B. Select an ID site using the volar surface of the forearm
• C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
• D. Ensure that the needle is inserted into the skin with the bevel up

Correct answer: A

Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.

4. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

• A. Altered consciousness within the first 24 hours after injury
• B. Confusion immediately following the injury
• C. Headache that resolves quickly
• D. Brief loss of consciousness with a lucid interval

Correct answer: A

Rationale: The correct answer is A. Epidural hematoma often presents with a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness. Therefore, altered consciousness within the first 24 hours after the injury is indicative of a developing epidural hematoma. Choices B, C, and D are incorrect because confusion immediately following the injury, headache that resolves quickly, and brief loss of consciousness with a lucid interval are not specific signs of epidural hematoma.

5. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Respiratory acidosis

Correct answer: B

Rationale: Pyloric stenosis often leads to metabolic alkalosis due to the loss of gastric acid from vomiting. Metabolic acidosis would not be expected in pyloric stenosis as there is no excessive acid accumulation. Respiratory alkalosis and respiratory acidosis are not typically associated with pyloric stenosis, making them incorrect choices.

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