Nursing Elites

1. A nurse working in a surgical unit notices a patient experiencing SOB, calf pain, and warmth over the posterior calf. All of these symptoms may indicate which of the following medical conditions?

• A. Patient may have a DVT.
• B. Patient may be exhibiting signs of dermatitis.
• C. Patient may be in the late stages of CHF.
• D. Patient may be experiencing anxiety after surgery.

Correct answer: A

Rationale: The correct answer is that the patient may have a DVT (Deep Vein Thrombosis). SOB (Shortness of Breath), calf pain, and warmth over the posterior calf are classic signs and symptoms of DVT. DVT is a serious condition where a blood clot forms in a deep vein, commonly in the legs. Choices B, C, and D are incorrect because dermatitis does not typically present with these symptoms, late stages of CHF would manifest with other signs, and anxiety after surgery usually does not produce these specific symptoms.

2. On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?

• A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
• B. Hold medications and notify the physician
• C. Arouse the client and give some orange juice with sugar packets added
• D. Give the medications as ordered and re-check blood sugar in one hour

Correct answer: A

Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.

3. A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP"?nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?

• A. Cushingoid appearance
• B. Alopecia
• C. Temporary or permanent sterility
• D. Pathologic fractures

Correct answer: B

Rationale: The correct answer is B: alopecia. Chemotherapy drugs like vincristine and nitrogen mustard commonly cause hair loss (alopecia), which can significantly impact body image. While a Cushingoid appearance can be a side effect of long-term steroid use, it is not typically associated with the chemotherapy regimen mentioned. Temporary or permanent sterility can result from chemotherapy, affecting fertility but not directly contributing to altered body image. Pathologic fractures are not commonly linked to Hodgkin's disease or its treatment, unlike alopecia which is a well-known side effect.

4. What should the nurse do while caring for a client with an eating disorder?

• A. Encourage the client to cook for others
• B. Weigh the client daily and keep a journal
• C. Restrict access to mirrors
• D. Monitor food intake and behavior for one hour after meals

Correct answer: D

Rationale: The correct answer is to monitor food intake and behavior for one hour after meals. This is crucial in caring for a client with an eating disorder as it helps in assessing any immediate risks related to the disorder. Option A is incorrect as it may trigger additional stress for the client and distract from the main focus of managing the disorder. Option B, weighing the client daily, could lead to an unhealthy focus on weight and potentially worsen the client's mental health. Option C, restricting access to mirrors, although it may be beneficial for body image concerns, does not directly address the core issue of monitoring food intake and behavior, which is essential in managing eating disorders.

5. Which of the following is not a primary function of the kidneys?

• A. blood pressure control
• B. vitamin D activation
• C. erythropoietin production
• D. reabsorption of waste products

Correct answer: D

Rationale: The correct answer is reabsorption of waste products because the kidneys excrete waste products rather than reabsorbing them. Choices A, B, and C are indeed primary functions of the kidneys. The kidneys play a crucial role in regulating blood pressure, activating vitamin D, and producing erythropoietin, which stimulates red blood cell production. Therefore, the primary role of the kidneys is to filter blood, remove waste products, regulate fluid balance, and maintain electrolyte balance.

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