Nursing Elites

1. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8°F, blood pressure 90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse assesses the client's findings, they include a mottled skin appearance and confusion. Which action should the nurse take first?

• A. Obtain a wound specimen for culture.
• B. Initiate an infusion of intravenous (IV) fluids.
• C. Transfer the client to the ICU.
• D. Assess the client's core temperature.

Correct answer: B

Rationale: The correct action for the nurse to take first is to initiate an infusion of intravenous (IV) fluids. In this scenario, the client is showing signs of sepsis, indicated by a high temperature, low blood pressure, rapid heart rate, and increased respiratory rate. Mottled skin appearance and confusion are also signs of poor perfusion. Initiating IV fluids is crucial in treating sepsis to maintain blood pressure and perfusion. Obtaining a wound specimen for culture (Choice A) can be important but is not the priority at this moment. Transferring the client to the ICU (Choice C) can be considered after stabilizing the client. Assessing the client's core temperature (Choice D) is not the immediate priority compared to addressing the signs of sepsis and poor perfusion.

2. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?

• A. Inflammation of the vessels
• B. Obstructed blood flow
• C. Overhydration
• D. Stress-related headaches

Correct answer: B

Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.

3. A client with peptic ulcer disease is prescribed sucralfate. What is the mechanism of action of this medication?

• A. Neutralizes stomach acid
• B. Decreases gastric acid secretion
• C. Covers the ulcer site and protects it from acid
• D. Improves gastric motility

Correct answer: C

Rationale: The correct answer is C: Covers the ulcer site and protects it from acid. Sucralfate works by forming a protective barrier over ulcers, shielding them from stomach acid and promoting healing. Choice A, neutralizing stomach acid, is incorrect as sucralfate does not neutralize acid but acts as a physical barrier. Choice B, decreasing gastric acid secretion, is not the mechanism of action of sucralfate. Choice D, improving gastric motility, is unrelated to sucralfate's action on peptic ulcers.

4. How should the nurse record the observation of a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands?

• A. Hand assistance
• B. Leg crawling
• C. Gowers sign
• D. Bright sign

Correct answer: C

Rationale: The correct term for a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands is known as the Gowers sign. This maneuver is characteristic of Duchenne muscular dystrophy due to proximal muscle weakness. Choices A, B, and D are incorrect because they do not specifically describe the action of walking up the thighs with the hands, which is a distinctive feature of the Gowers sign.

5. A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question?

• A. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
• B. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
• C. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
• D. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.

Correct answer: D

Rationale: With a CD4+ T cell count of 200 cells/microliter, the client's immune system is severely compromised, leading to opportunistic infections.

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