Nursing Elites

1. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?

• A. Bounding erratic pulse.
• B. Regularly irregular pulse.
• C. Thready irregular pulse.
• D. No palpable pulse.

Correct answer: D

Rationale: Ventricular fibrillation is a life-threatening arrhythmia characterized by chaotic, asynchronous contractions of the ventricles, resulting in ineffective cardiac output. This leads to the absence of a palpable pulse. Nurses should be prepared to initiate immediate interventions such as defibrillation to restore normal cardiac rhythm in a client experiencing ventricular fibrillation.

2. Which of the following statements is true about ischemic colitis?

• A. Typically requires colonic resection
• B. Affects the watershed areas of the colon, namely, the splenic flexure, right colon, and rectum
• C. Is only seen in the elderly
• D. Requires colonoscopic intervention

Correct answer: B

Rationale: Ischemic colitis most often results from low-flow states associated with hypotension or poor perfusion. As a result, the vascular watershed areas of the colon, including the splenic flexure, right colon, and rectum, are at highest risk of ischemic injury. Therefore, option B is correct as it accurately identifies the areas commonly affected by ischemic colitis.

3. A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Correct answer: C

Rationale: Stage 3 hepatic encephalopathy is characterized by confusion, difficulty arousing from sleep, and rigidity of extremities. These symptoms indicate advanced manifestations of hepatic encephalopathy, requiring prompt intervention and monitoring to prevent further neurological deterioration.

4. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which finding should the nurse report to the healthcare provider immediately?

• A. Weight gain.
• B. Dry mouth.
• C. Muscle rigidity.
• D. Drowsiness.

Correct answer: C

Rationale: Muscle rigidity is a crucial finding to report immediately as it can indicate neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction to antipsychotic medications. NMS is characterized by muscle rigidity, high fever, autonomic dysfunction, and altered mental status. Prompt recognition and intervention are essential to prevent serious complications or death.

5. What is the primary advantage of prescribing rivaroxaban over warfarin for a patient with a history of deep vein thrombosis (DVT)?

• A. No need for regular INR monitoring
• B. Lower risk of bleeding
• C. Fewer dietary restrictions
• D. Longer half-life

Correct answer: A

Rationale: The primary advantage of prescribing rivaroxaban over warfarin for a patient with a history of deep vein thrombosis (DVT) is that rivaroxaban does not require regular INR monitoring. This eliminates the need for frequent blood tests to adjust the dosage, making it more convenient for patients to manage their anticoagulant therapy.

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