Nursing Elites

1. A patient is on bedrest 24 hours after a hip fracture. Which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?

• A. Performing passive, light range-of-motion exercises on the hip as tolerated.
• B. Assess the patient's mental status for drowsiness or sleepiness.
• C. Assess the pedal pulse and capillary refill in the toes.
• D. Administer a stool softener as ordered.

Correct answer: B

Rationale: In detecting or preventing Fat Embolism Syndrome (FES), assessing the patient's mental status for drowsiness or sleepiness is crucial. Decreased level of consciousness is an early sign of FES due to decreased oxygen levels. Performing passive, light range-of-motion exercises on the hip may not directly relate to FES. Assessing pedal pulse and capillary refill in the toes is essential for assessing circulation but not specific to detecting FES. Administering a stool softener, while important for preventing constipation in immobilized patients, is not directly related to detecting or preventing FES.

2. The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

• A. Hemoglobin
• B. Temperature
• C. Activity level
• D. Albumin level

Correct answer: D

Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. In this case, monitoring the albumin level is crucial to assess the patient's fluid balance and potential for edema. While hemoglobin, temperature, and activity level are important parameters to monitor in a patient's assessment, they are not directly associated with the patient's current symptoms of toxic hepatitis and edema development. Therefore, the correct choice is the albumin level.

3. What action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?

• A. Decrease the patient's evening fluid intake.
• B. Teach the patient how to use the Cred method.
• C. Suggest the use of adult incontinence briefs for nighttime only.
• D. Assist the patient to the commode every 2 hours during the day.

Correct answer: B

Rationale: For a 40-year-old patient with multiple sclerosis experiencing urinary retention due to a flaccid bladder, teaching the Cred method is the appropriate action. The Cred method involves applying manual pressure over the bladder to aid in bladder emptying. Decreasing fluid intake is not the correct approach as it will not address the underlying issue of bladder emptying and may lead to dehydration and urinary tract infections. Using adult incontinence briefs only addresses the symptom of incontinence without addressing the bladder emptying problem. Assisting the patient to the commode every 2 hours does not actively address the issue of improving bladder emptying as effectively as teaching the Cred method.

4. Which of the following signs is NOT indicative of increased intracranial pressure?

• A. Decreased level of consciousness
• B. Projectile vomiting
• C. Sluggish pupil dilation
• D. Increased heart rate

Correct answer: D

Rationale: Increased intracranial pressure can lead to serious complications if not promptly addressed. Common signs of increased intracranial pressure include decreased level of consciousness, sluggish pupil dilation, abnormal respirations, and projectile vomiting. However, an increased heart rate is not a typical sign associated with increased intracranial pressure. It is important for healthcare providers to recognize these signs early to prevent severe consequences such as brain herniation.

5. A patient asks the nurse whether he is a good candidate to use a CPAP machine. The nurse reviews the client's history. Which condition would contraindicate the use of a CPAP machine?

• A. The patient is in the late stage of dementia.
• B. The patient has a history of bronchitis.
• C. The patient has had suicidal gestures/attempts in the past.
• D. The patient is on beta-blockers.

Correct answer: A

Rationale: The correct answer is that the patient is in the late stage of dementia. In late-stage dementia, individuals may have an inability to follow commands and understand instructions independently, which are essential for proper installation and use of a CPAP machine. This makes using a CPAP machine challenging and potentially ineffective for patients in this condition. Choice B, having a history of bronchitis, does not contraindicate the use of a CPAP machine. In fact, CPAP therapy can be beneficial for patients with respiratory conditions like bronchitis. Choice C, a history of suicidal gestures/attempts, while concerning for the patient's mental health, does not directly contraindicate the use of a CPAP machine. Choice D, being on beta-blockers, is not a contraindication for CPAP machine use. Beta-blockers are commonly used medications for various conditions and do not interfere with the use of a CPAP machine.

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