Nursing Elites

1. A client with severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?

• A. Elevated blood pressure.
• B. Fever and chills.
• C. Increased urine output.
• D. Bradycardia.

Correct answer: B

Rationale: Fever and chills are classic signs of a transfusion reaction. These symptoms indicate that the body is having a response to the transfused blood, possibly due to incompatibility or an immune reaction. Elevated blood pressure (choice A) is not a typical sign of a transfusion reaction. Increased urine output (choice C) and bradycardia (choice D) are also not characteristic signs of a transfusion reaction. It is crucial to recognize symptoms of a transfusion reaction promptly to prevent further complications and ensure appropriate management.

2. A 35-year-old man presents with fatigue, weight loss, and hyperpigmentation of the skin. Laboratory tests reveal hyponatremia, hyperkalemia, and low cortisol levels. What is the most likely diagnosis?

• A. Cushing's syndrome
• B. Addison's disease
• C. Hypothyroidism
• D. Pheochromocytoma

Correct answer: B

Rationale: The clinical presentation of a 35-year-old man with fatigue, weight loss, hyperpigmentation of the skin, hyponatremia, hyperkalemia, and low cortisol levels is classic for Addison's disease. These findings are consistent with primary adrenal insufficiency, where the adrenal glands fail to produce adequate cortisol. In Addison's disease, the adrenal cortex is damaged, leading to decreased cortisol production and elevated levels of ACTH. This results in symptoms such as fatigue, weight loss, and hyperpigmentation due to increased ACTH production stimulating melanocytes. Hyponatremia and hyperkalemia are common electrolyte abnormalities seen in Addison's disease due to aldosterone deficiency. Therefore, the correct diagnosis in this case is Addison's disease.

3. A 62-year-old male client with a history of coronary artery disease complains that his heart is 'racing' and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at 2 liters per nasal cannula. Based on the rhythm shown, which prescription should the nurse administer?

• A. Give magnesium via secondary infusion.
• B. Initiate IV heparin solution as per protocol.
• C. Administer IV adenosine (Adenocard).
• D. Prepare for synchronized cardioversion.

Correct answer: C

Rationale: Administering IV adenosine is the appropriate intervention for a client with symptomatic tachycardia to restore normal sinus rhythm. Adenosine is a medication used to treat supraventricular tachycardia (SVT) by interrupting the reentry pathways through the AV node and restoring normal sinus rhythm. It is a rapid-acting medication given as a rapid IV push followed by a saline flush. The dose is typically administered in a healthcare setting where cardiac monitoring is available due to its potential to cause transient asystole.

4. When creating a care plan for a 70-year-old obese client admitted to the postsurgical unit following a colon resection, the client's age and increased body mass index put them at increased risk for which complication in the postoperative period?

• A. Hyperglycemia
• B. Azotemia
• C. Falls
• D. Infection

Correct answer: D

Rationale: Infection is a significant risk in obese, elderly clients due to decreased immunity and increased healing time, making them more susceptible to postoperative infections. Proper infection prevention measures should be a priority in the care plan for this client to minimize this risk.

5. A 60-year-old man presents with fatigue, weight gain, and constipation. Laboratory tests reveal low TSH and high free T4 levels. What is the most likely diagnosis?

• A. Hypothyroidism
• B. Hyperthyroidism
• C. Thyroiditis
• D. Thyroid cancer

Correct answer: B

Rationale: The combination of low TSH and high free T4 levels is characteristic of hyperthyroidism, not hypothyroidism. Hyperthyroidism is associated with symptoms such as fatigue, weight loss, and diarrhea, contrasting with the typical presentation of hypothyroidism. Therefore, in this case, the most likely diagnosis is hyperthyroidism.

Similar Questions