Nursing Elites

1. After a transsphenoidal hypophysectomy, the nurse should assess the client for:

• A. Cerebrospinal fluid (CSF) leak.
• B. Fluctuating blood glucose levels.
• C. Cushing's syndrome.
• D. Cardiac arrhythmias.

Correct answer: A

Rationale: Following a transsphenoidal hypophysectomy, assessing the client for a cerebrospinal fluid (CSF) leak is crucial due to the risk of this serious complication. A CSF leak can lead to infection and increased intracranial pressure, which must be promptly identified and managed to prevent further complications. Fluctuating blood glucose levels (Choice B) are not directly associated with a transsphenoidal hypophysectomy. Cushing's syndrome (Choice C) is a condition related to prolonged exposure to high levels of cortisol and is not a common immediate concern post-transsphenoidal hypophysectomy. Cardiac arrhythmias (Choice D) are not typically a direct complication of this surgical procedure, making it a less relevant concern compared to a CSF leak.

2. A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should tell the client that:

• A. The test may be painful
• B. The test takes 2 to 3 hours
• C. Food and fluids are not allowed for 4 hours after the test
• D. Dye is injected and may cause a warm flushing sensation

Correct answer: D

Rationale: The correct answer is D. A contrast-aided CT scan involves the injection of dye to enhance the images obtained. The dye may cause a warm flushing sensation when injected, which is a common side effect. Choices A, B, and C are incorrect. CT with contrast is generally not a painful procedure, the duration of the test does not usually take 2 to 3 hours, and restrictions on food and fluids are typically before the test, not afterward.

3. A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:

• A. HIV infection has been confirmed
• B. The client probably has an opportunistic infection
• C. The test will need to be confirmed with the use of a Western blot
• D. A positive test is a normal result and does not mean that the client is infected with HIV

Correct answer: C

Rationale: When an ELISA test for HIV is positive, it is essential to confirm the result with a Western blot. The Western blot is the confirmatory test for HIV. Choice A is incorrect because a positive ELISA test does not confirm HIV infection. Choice B is incorrect as it assumes a different diagnosis. Choice D is incorrect because a positive ELISA test does indicate potential HIV infection and requires confirmation.

4. Which of the following is a key symptom of myocardial infarction (MI)?

• A. Chest pain.
• B. Shortness of breath.
• C. Nausea.
• D. Fatigue.

Correct answer: A

Rationale: The correct answer is A: Chest pain. Chest pain is a hallmark symptom of myocardial infarction (MI) due to inadequate blood flow to the heart muscle. This pain can be severe, crushing, or squeezing, and may radiate to the left arm, jaw, or back. Shortness of breath (choice B), nausea (choice C), and fatigue (choice D) can accompany MI but are not as specific or characteristic as chest pain in diagnosing this condition. Therefore, chest pain is the primary symptom to recognize for suspected MI.

5. During a routine clinic visit, a nurse is assessing a 48-year-old client with a history of smoking. The client, who exercises regularly, reports calf pain during exercise that disappears at rest. Which of the following findings requires further evaluation?

• A. Heart rate of 57 bpm.
• B. SpO2 of 94% on room air.
• C. Blood pressure of 134/82.
• D. Ankle-brachial index of 0.65.

Correct answer: D

Rationale: An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client experiencing intermittent claudication, indicating compromised blood flow to the lower extremities during exercise. This finding requires further evaluation to assess the severity of arterial insufficiency and determine appropriate interventions. Choice A (Heart rate of 57 bpm) is within the normal range for an adult at rest and indicates good cardiovascular fitness. Choice B (SpO2 of 94% on room air) is slightly lower than the normal range but is generally acceptable in a healthy individual. Choice C (Blood pressure of 134/82) falls within the normal range and does not raise immediate concerns in this context.

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