Nursing Elites

1. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.

2. A nurse is assessing a client who has hyperthyroidism. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Dry skin.
• C. Cold intolerance.
• D. Tachycardia.

Correct answer: D

Rationale: The correct answer is D: Tachycardia. In clients with hyperthyroidism, tachycardia is a common finding due to the increased metabolic rate. Weight loss and heat intolerance are also expected due to the elevated metabolism. Choices A, B, and C (Weight gain, dry skin, cold intolerance) are not typical findings in hyperthyroidism, as the condition is associated with an overactive thyroid gland leading to an increase in metabolic functions.

3. What is the best way to manage a patient's pain postoperatively?

• A. Administer analgesics regularly
• B. Administer pain medication PRN
• C. Encourage deep breathing exercises
• D. Provide distraction techniques

Correct answer: A

Rationale: The correct answer is A: Administer analgesics regularly. Postoperative pain management often requires a scheduled, around-the-clock administration of analgesics to maintain a consistent level of pain relief and minimize the risk of breakthrough pain. Choice B, administering pain medication PRN (as needed), may lead to inadequate pain control as the medication is not given preemptively. Choice C, encouraging deep breathing exercises, can be beneficial for pain management but should be used as an adjunct to analgesic therapy. Choice D, providing distraction techniques, may help some patients cope with pain but should not be the primary method of pain management postoperatively.

4. A patient is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

• A. Prime IV tubing with 0.9% sodium chloride
• B. Use a 24-gauge IV catheter
• C. Obtain filterless IV tubing
• D. Place blood in the warmer for 1 hour

Correct answer: A

Rationale: Priming the IV tubing with 0.9% sodium chloride is crucial before administering packed RBCs as it prevents hemolysis and ensures the safe transfusion of blood. Using a smaller 20- to 22-gauge IV catheter is recommended for packed RBCs to prevent hemolysis due to the small tubing size and faster flow rate. Obtaining filterless IV tubing is incorrect as blood products should be administered through a specialized filter to prevent potential clots or contaminants from reaching the patient. Placing blood in the warmer for an hour is unnecessary and could lead to overheating, potentially causing harm to the patient.

5. A nurse is assessing a client with a history of post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

• A. Dependence on family and friends
• B. Loss of interest in usual activities
• C. Ritualistic behavior
• D. Passive-aggressive behavior

Correct answer: B

Rationale: The correct answer is B: Loss of interest in usual activities. Clients with PTSD often exhibit symptoms such as numbing, which can manifest as a loss of interest in activities they once enjoyed. Choice A, dependence on family and friends, is more indicative of seeking support rather than a direct symptom of PTSD. Choice C, ritualistic behavior, is more commonly associated with conditions like obsessive-compulsive disorder. Choice D, passive-aggressive behavior, is not a typical finding in clients with PTSD.

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