Nursing Elites

1. A client with HIV/AIDS is receiving zidovudine (Retrovir). The nurse should monitor the client for which of the following adverse effects?

• A. Hyperglycemia
• B. Anemia
• C. Hypertension
• D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is B: Anemia. Zidovudine (Retrovir) can cause bone marrow suppression, leading to anemia. Monitoring for signs of anemia, such as fatigue, pallor, and shortness of breath, is crucial. Choice A, Hyperglycemia, is not a common adverse effect of zidovudine. Choice C, Hypertension, is not directly associated with zidovudine use. Choice D, Hypercalcemia, is also not a typical adverse effect of zidovudine.

2. Which of the following patients should the home care nurse assess first?

• A. A 65-year-old male with known COPD and difficulty breathing after climbing a flight of stairs.
• B. A 78-year-old with CHF who has gained 4 lbs according to her tele-monitoring.
• C. A 50-year-old with bilateral leg swelling and difficulty walking.
• D. A 60-year-old with lower back pain.

Correct answer: A

Rationale: The correct answer is A. A patient with known COPD and difficulty breathing after physical exertion like climbing stairs requires immediate assessment by the nurse. This could indicate a potential exacerbation of COPD, which needs prompt intervention to prevent respiratory distress. Choices B, C, and D describe important patient situations that also require attention, but the urgency is higher with a COPD patient experiencing difficulty breathing.

3. The nurse uses the DRG (Diagnosis Related Group) manual to

• A. Classify nursing diagnoses from the client's health history
• B. Identify findings related to a medical diagnosis
• C. Determine reimbursement for a medical diagnosis
• D. Implement nursing care based on case management protocol

Correct answer: C

Rationale: The DRG manual is used to determine the reimbursement rate for medical diagnoses and treatments under the prospective payment system used by healthcare facilities. Choice A is incorrect because the DRG manual is not used to classify nursing diagnoses, but rather to group medical diagnoses for billing purposes. Choice B is incorrect as the DRG manual is not used to identify findings related to medical diagnoses, but rather to standardize payments for medical services. Choice D is incorrect as the DRG manual is not used to implement nursing care based on case management protocol, but rather to set reimbursement rates.

4. In the implementation of the national family planning program, the government assumes the role of a:

• A. decision-maker in the practice of family planning methods
• B. regulator
• C. facilitator
• D. dictator

Correct answer: C

Rationale: The correct answer is C: 'facilitator.' In the implementation of a national family planning program, the government plays a role as a facilitator, meaning it helps to support and enable the access to family planning services and information. The government's role is to ensure that services are available, accessible, and of good quality, rather than making decisions for individuals or regulating them. Choices A, B, and D are incorrect because the government's role is not to make decisions on behalf of individuals (decision-maker), strictly regulate family planning practices (regulator), or impose decisions without considering individual choices (dictator).

5. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?

• A. Pleuritic pain on inspiration
• B. Dry mucus membranes in the mouth
• C. A decrease in respiratory rate from 34 to 24
• D. Decrease in chest wall expansion

Correct answer: D

Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.

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