Nursing Elites

1. A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?

• A. Reassure the patient that pain is normal following surgery.
• B. Administer prn Nifedipine and assess the client's response.
• C. Administer prn Meperidine HCL and assess the client's response.
• D. Recheck BP and pulse rate every 20 minutes for the next hour.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.

2. Signs of impaired breathing in infants and children include all of the following except:

• A. nasal flaring
• B. grunting
• C. seesaw breathing
• D. quivering lips

Correct answer: D

Rationale: Signs of impaired breathing in infants and children can manifest in various ways. Nasal flaring, grunting, and seesaw breathing are all indicative of respiratory distress in pediatric patients. Nasal flaring is the widening of the nostrils with breathing effort, grunting is a sound made during exhalation to try to keep the airways open, and seesaw breathing involves the chest moving in the opposite direction of the abdomen. However, quivering lips are not typically associated with impaired breathing in this context. Lip quivering is a distracter and not a common sign of respiratory distress in infants and children. Therefore, the correct answer is 'quivering lips.'

3. A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?

• A. "I became dizzy when I stood up."?
• B. "I was nauseated and began vomiting."?
• C. "The pain started in my chest and stopped after I sat down."?
• D. "The pain began with a migraine and progressed to numbness in my left arm."?

Correct answer: B

Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.

4. The nurse is caring for a client with hyperemesis gravidarum. What is the most likely electrolyte imbalance?

• A. Hypocalcemia
• B. Hypomagnesemia
• C. Hyponatremia
• D. Hypokalemia

Correct answer: D

Rationale: In hyperemesis gravidarum, where the client experiences severe nausea and vomiting, the most likely electrolyte imbalance is hypokalemia. Potassium is abundant in the stomach, and excessive vomiting leads to potassium loss. Hypocalcemia (Choice A) is not typically associated with hyperemesis gravidarum. Hypomagnesemia (Choice B) and Hyponatremia (Choice C) are less likely to occur compared to hypokalemia in this condition.

5. A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client?

• A. "You should discuss the inheritance risk with your physician."?
• B. "Sickle cell disease is genetically based and might be passed on to children."?
• C. "Sickle cell disease is genetically based and is not passed on to children."?
• D. "Sickle cell disease is caused by an infection and cannot be passed on to children."?

Correct answer: B

Rationale: A client with sickle cell disease has a genetic condition that can be passed on to their offspring. The most appropriate statement for the PN to provide is to acknowledge this fact and inform the client that sickle cell disease is genetically based and might be passed on to children. This empowers the client with accurate information. Choice A has been refined to emphasize discussing the inheritance risk, making it a better option than the vague original choice. Choices C and D provide incorrect information. Sickle cell disease is indeed genetically based and can be inherited.

Similar Questions