Nursing Elites

1. Which anatomical location is associated with the deep tendon reflex known as the patellar reflex?

• A. Knee picture
• B. Ankle picture
• C. Elbow picture
• D. Wrist picture

Correct answer: A

Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.

2. The nurse is caring for a 17-month-old child with acetaminophen poisoning. Which laboratory reports should the nurse review first?

• A. Prothrombin time (PT) and partial thromboplastin time (PTT)
• B. Red blood cell and white blood cell counts
• C. Blood urea nitrogen and creatinine levels
• D. Liver enzymes (AST and ALT)

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the drug's metabolism in the liver. Monitoring liver enzymes such as AST and ALT is crucial as they indicate liver function and damage. Prothrombin time (PT) and partial thromboplastin time (PTT) (Choice A) are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts (Choice B) are not directly related to acetaminophen poisoning. Blood urea nitrogen and creatinine levels (Choice C) assess kidney function, but liver enzymes are more specific for evaluating liver damage in acetaminophen poisoning.

3. A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and 'not feeling well.' The nurse notes warmth, edema, induration, and red streaking on the client’s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?

• A. Obtain a specimen for culture.
• B. Apply a warm compress.
• C. Administer analgesics.
• D. Discontinue the infusion.

Correct answer: D

Rationale: Discontinuing the infusion is the first step in addressing potential complications such as phlebitis or infection. It is crucial to prevent further infusion-related damage by stopping the source of the issue. Obtaining a specimen for culture (Choice A) can be considered later to identify the specific microorganism causing the infection. Applying a warm compress (Choice B) or administering analgesics (Choice C) may provide comfort but do not address the underlying issue of infection or phlebitis, which requires immediate intervention by discontinuing the infusion.

4. A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client’s abdomen, the nurse expects the bowel sounds to be:

• A. Absent
• B. Hyperactive
• C. Normal
• D. Hypoactive

Correct answer: A

Rationale: In paralytic ileus, bowel sounds are typically absent or significantly reduced due to decreased motility of the intestines. This absence of bowel sounds is a key characteristic used in diagnosing paralytic ileus. Hyperactive bowel sounds are not expected in this condition as there is a lack of normal peristalsis. Normal bowel sounds would not be present in paralytic ileus, and hypoactive bowel sounds, which indicate decreased bowel motility, are more commonly associated with conditions like postoperative ileus or constipation, rather than paralytic ileus.

5. In an emergency department, a nurse is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hours. Which of the following actions should the nurse take first?

• A. Auscultate bowel sounds.
• B. Administer an antiemetic.
• C. Offer pain medication.
• D. Palpate the abdomen.

Correct answer: A

Rationale: The correct action the nurse should take first is to auscultate bowel sounds. This step is crucial to assess bowel activity before proceeding with palpation or administering medications. Assessing bowel sounds can provide valuable information about bowel motility and potential obstructions. Administering an antiemetic or offering pain medication may be necessary but should come after assessing bowel sounds to ensure appropriate treatment. Palpating the abdomen should be avoided initially to prevent potential discomfort or complications, especially if there is suspected abdominal pathology.

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