Nursing Elites

1. A patient with chronic pain is prescribed a fentanyl patch. What is the most important instruction for the nurse to provide?

• A. Apply the patch to a different site each time.
• B. Change the patch every 72 hours.
• C. Avoid using additional heating pads over the patch.
• D. Remove the patch before showering.

Correct answer: B

Rationale: The most important instruction for the nurse to provide to a patient prescribed a fentanyl patch is to change the patch every 72 hours. This ensures consistent pain control and prevents complications. It is crucial to rotate the application sites to prevent skin irritation or reactions. Using additional heating pads over the patch should be avoided as it can increase the absorption of the medication, leading to overdose or adverse effects. Removing the patch before showering is not necessary as long as the patch is securely in place.

2. A 68-year-old man with a history of diabetes, hypertension, and coronary artery disease (s/p coronary artery bypass graft two years ago) presents to the emergency room with fevers and left-sided abdominal pain. His physical examination reveals a temperature of 101.5°F, pulse 96, and blood pressure of 135/80. His abdomen is soft with moderate left lower quadrant tenderness. There is no rebound or guarding. Bowel sounds are present. A CT scan is done which reveals inflammation around an area of the left colon. The next step in his workup/management should be

• A. Antibiotic therapy with ciprofloxacin and metronidazole
• B. Referral for urgent colonoscopy
• C. Referral to a surgeon for immediate hemicolectomy
• D. Barium enema

Correct answer: A

Rationale: The patient's presentation is consistent with diverticulitis without evidence of perforation or abscess formation on CT scan. During acute infections, procedures like barium enema and colonoscopy should be avoided to prevent the risk of perforation. Urgent surgery is not indicated initially. The appropriate next step is to start antibiotic therapy aimed at gram-negative aerobes and anaerobes, such as ciprofloxacin and metronidazole, which are the initial treatment of choice for diverticulitis.

3. A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?

• A. Apply a hypothermia unit to stabilize core temperature.
• B. Increase the client's IV fluid rate to 200 ml/hr.
• C. Call the hospital chaplain to counsel the family.
• D. Draw blood cultures x3 to detect infection.

Correct answer: B

Rationale: The correct answer is to increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate signs of shock and hypovolemia, making fluid resuscitation the priority to address these conditions. Improving intravascular volume is crucial to stabilize the client's blood pressure, heart rate, and urine output, ultimately improving organ perfusion and addressing the underlying issue of hypovolemia.

4. Which problem in a client requires the most immediate intervention by the nurse?

• A. Finger paresthesias related to carpal tunnel syndrome.
• B. Increasing sharp pain related to compartment syndrome.
• C. Increasing burning pain related to a Morton's neuroma.
• D. Increasing sharp pain related to plantar fasciitis.

Correct answer: B

Rationale: The correct answer is B: Increasing sharp pain related to compartment syndrome. Compartment syndrome is a serious condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. Immediate intervention is crucial to prevent permanent damage to muscles and nerves, including tissue necrosis and nerve injury. Choices A, C, and D do not present the same level of urgency as compartment syndrome, making them less critical for immediate intervention. Carpal tunnel syndrome, Morton's neuroma, and plantar fasciitis may cause discomfort and functional limitations but are not typically considered emergencies requiring urgent intervention like compartment syndrome.

5. An otherwise healthy 45-year-old man presents with severe hematochezia and moderate abdominal cramping since this morning. A barium enema one year ago was normal. On examination, his blood pressure is 120/78 and pulse is 100 while lying; when standing, the blood pressure is 110/76 and pulse is 136. His hematocrit is 34. What is the most likely cause of bleeding?

• A. Diverticular bleed
• B. Duodenal ulcer
• C. Inflammatory bowel disease
• D. Vascular ectasia (watermelon stomach)

Correct answer: B

Rationale: The patient's presentation with hematochezia, moderate abdominal cramping, and hemodynamic changes (increased pulse on standing) suggests an upper gastrointestinal bleed. The drop in blood pressure and rise in pulse rate when standing indicate orthostatic hypotension, which is a sign of significant blood loss. The absence of melena does not rule out an upper GI bleed. Ulcers in the duodenal bulb can erode into the gastroduodenal artery, leading to brisk blood loss. A normal barium enema one year ago makes diverticular bleeding less likely. Inflammatory bowel disease usually does not cause severe acute GI bleeding unless there is ulceration into a vessel. Vascular ectasia, like watermelon stomach, typically presents with chronic blood loss and iron deficiency anemia, more common in older women. The absence of vomiting and the presence of hematochezia make Mallory-Weiss tear less likely in this case.

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