Nursing Elites

1. Based on this strip, what is the interpretation of this rhythm?

• A. Atrial fibrillation.
• B. Ventricular tachycardia.
• C. Normal sinus rhythm.
• D. Second-degree heart block.

Correct answer: C

Rationale: The correct answer is C, Normal sinus rhythm. Normal sinus rhythm is characterized by a regular rhythm, normal P waves, and a consistent PR interval. In this context, the strip likely shows a normal ECG pattern with these characteristics, indicating a healthy heart rhythm. Choices A, B, and D are incorrect. Atrial fibrillation would show an irregularly irregular rhythm with no discernible P waves. Ventricular tachycardia would display wide QRS complexes and a fast heart rate. Second-degree heart block would exhibit intermittent dropped QRS complexes.

2. A middle-aged man who has a 35-year smoking history presents to the emergency department confused and short of breath. Before starting oxygen, these baseline arterial blood gases (ABGs) are obtained: pH=7.25, pCO2=50 mmHg, HCO3=30 mEq/L. These findings indicate to the nurse that the client is experiencing which acid-base imbalance?

• A. Metabolic acidosis.
• B. Respiratory acidosis.
• C. Metabolic alkalosis.
• D. Respiratory alkalosis.

Correct answer: B

Rationale: The ABG results show a low pH (acidosis) and increased pCO2, indicating respiratory acidosis. In respiratory acidosis, the lungs cannot remove enough CO2, leading to its accumulation in the blood. This often occurs in conditions like COPD and is consistent with the patient's smoking history. Metabolic acidosis (choice A) is characterized by low pH and low HCO3 levels. Metabolic alkalosis (choice C) is marked by high pH and high HCO3 levels. Respiratory alkalosis (choice D) presents with high pH and low pCO2.

3. A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?

• A. Irregular apical pulse
• B. Purple marks on the skin of the abdomen
• C. Quarter-sized blood spot on the dressing
• D. Pitting ankle edema

Correct answer: A

Rationale: The correct answer is A: Irregular apical pulse. In a client recovering from a laparoscopic procedure with Cushing's Syndrome, an irregular apical pulse can be indicative of a life-threatening arrhythmia and requires immediate intervention. Choices B, C, and D are not as urgent as an irregular apical pulse. Purple marks on the skin of the abdomen may be related to Cushing's Syndrome, a quarter-sized blood spot on the dressing can be managed with appropriate wound care, and pitting ankle edema may be expected postoperatively but does not require immediate intervention.

4. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?

• A. Check the blood glucose level
• B. Administer insulin immediately
• C. Offer a high-protein snack
• D. Place the client in a supine position

Correct answer: A

Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.

5. The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse?

• A. The causes of major depression are unknown.
• B. Major affective disorders in parents increase depression in children.
• C. Boys are more likely than girls to be depressed.
• D. The prevalence rate is higher in prepubescent children.

Correct answer: B

Rationale: The correct answer is B because while the exact causes of depression in children are not fully understood, research indicates that children are more likely to experience depression if their parents have a major affective disorder. Choice A is incorrect because it suggests that the causes of major depression are entirely unknown, which is not accurate. Choice C is incorrect as there is no conclusive evidence that boys are more likely than girls to be depressed. Choice D is incorrect as the prevalence rate of depression is not necessarily higher in prepubescent children specifically.

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