Nursing Elites

1. During a home health visit, a nurse consults with a male patient diagnosed with CAD and COPD who is taking Ventolin, Azmacort, Aspirin, and Theophylline and complains of upset stomach, nausea, and discomfort. What should the nurse do?

• A. Contact the patient's physician immediately
• B. Recommend the patient lie on his right side
• C. Advise the patient to schedule a doctor's visit the next day
• D. Suggest holding the drug Azmacort

Correct answer: A

Rationale: The correct answer is to contact the patient's physician immediately. The patient's symptoms of upset stomach, nausea, and discomfort could indicate theophylline toxicity, a potentially serious condition. It is crucial to consult the physician promptly to address this issue. Option B, recommending the patient lie on his right side, is incorrect as it does not address the potential theophylline toxicity and is not a priority. Option C, advising the patient to schedule a doctor's visit the next day, is inappropriate as the symptoms may indicate an urgent concern. Option D, suggesting holding the drug Azmacort, is incorrect as it does not address the potential theophylline toxicity and should not be done without consulting the physician first.

2. One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:

• A. cor pulmonale.
• B. atelectasis.
• C. pulmonary embolism.
• D. cardiac tamponade.

Correct answer: B

Rationale: The correct answer is atelectasis. The absence of breath sounds in the lower-right base is a key finding in atelectasis, which occurs when a portion of the lung collapses. The other symptoms such as dyspnea and increased respiratory rate could be present in various pulmonary conditions. Cor pulmonale is typically associated with chronic lung disease, pulmonary embolism presents with sudden onset dyspnea and chest pain, and cardiac tamponade manifests with Beck's triad of hypotension, distended neck veins, and muffled heart sounds.

3. The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?

• A. Hypocalcemia.
• B. Hyponatremia.
• C. Hyperkalemia.
• D. Hypophosphatemia.

Correct answer: A.

Rationale: The correct answer is Hypocalcemia. In hypoparathyroidism, where the parathyroid glands are not producing sufficient parathyroid hormone, calcium levels become inadequate. This leads to hypocalcemia, characterized by symptoms such as muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia are not typically associated with hypoparathyroidism. While hyperphosphatemia can be seen in hypoparathyroidism due to decreasing calcium levels, the question specifically asks about the primary electrolyte imbalance closely related to hypoparathyroidism, which is hypocalcemia.

4. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing is the property of another and must be treated with care.
• B. Such care facilitates repair and salvage of the clothing.
• C. The clothing of a trauma victim is potential evidence with legal implications.
• D. Such care decreases trauma to the family members receiving the clothing.

Correct answer: C

Rationale: The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.

5. A healthcare professional is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?

• A. Horizontal
• B. Sagittal
• C. Frontal
• D. Vertical

Correct answer: B

Rationale: The correct answer is 'Sagittal.' The sagittal plane divides the body into left and right halves, and movements in this plane involve flexion and extension. In this case, limited shoulder flexion on the left indicates a restriction in the forward and backward movement of the arm, which occurs in the sagittal plane. Choice A, 'Horizontal,' is incorrect as it refers to movements parallel to the ground. Choice C, 'Frontal,' is incorrect as it involves side-to-side movements. Choice D, 'Vertical,' is incorrect as it typically refers to up and down movements.

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