Nursing Elites

1. When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate the closest proximal pulse.
• B. Observe the color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.

2. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

• A. Orthostatic hypotension is a common side effect.
• B. Most antipsychotic drugs cause elevated blood pressure.
• C. This provides information on the amount of sodium allowed in the diet.
• D. It will indicate the need to institute antiparkinsonian drugs.

Correct answer: A

Rationale: Corrected Question: Monitoring blood pressure in clients receiving antipsychotic drugs is crucial because orthostatic hypotension is a common side effect. Orthostatic hypotension can lead to a sudden drop in blood pressure upon standing, increasing the risk of falls and related injuries. Therefore, regular blood pressure monitoring helps healthcare providers detect and manage this potential side effect. Incorrect Choices Rationale: - Choice B is incorrect because while antipsychotic drugs can have various side effects, causing elevated blood pressure is not a common effect associated with them. - Choice C is unrelated to blood pressure monitoring in clients receiving antipsychotic drugs. Monitoring blood pressure in this context aims to detect and manage side effects of the medication, not to assess sodium intake. - Choice D is incorrect as monitoring blood pressure in clients receiving antipsychotic drugs is primarily aimed at detecting orthostatic hypotension, not as an indicator for instituting antiparkinsonian drugs.

3. A client with hypothyroidism is prescribed levothyroxine. What should the nurse include in the teaching plan about this medication?

• A. Take the medication with a full meal
• B. Take the medication on an empty stomach
• C. Take the medication at bedtime
• D. Take the medication as needed for symptoms

Correct answer: B

Rationale: The correct answer is B: 'Take the medication on an empty stomach.' Levothyroxine should be taken on an empty stomach to enhance absorption and effectiveness. The medication is typically taken in the morning before breakfast. Choice A is incorrect because taking levothyroxine with a full meal can decrease its absorption. Choice C is incorrect because bedtime dosing may lead to insomnia. Choice D is incorrect because levothyroxine is a daily medication for hypothyroidism, not to be taken as needed for symptoms.

4. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?

• A. Administer prescribed nitroglycerin.
• B. Obtain a 12-lead electrocardiogram (ECG).
• C. Check the client's vital signs.
• D. Place the client on continuous telemetry.

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.

5. What pathophysiological events occur sequentially in the development of atherosclerosis?

• A. Foam cells release growth factors.
• B. Smooth muscle grows over fatty streaks creating fibrous plaques.
• C. Macrophages consume low-density lipoprotein (LDL) and create foam cells.
• D. Arterial endothelium injury causes inflammation.

Correct answer: D

Rationale: The correct sequence of pathophysiological events in the development of atherosclerosis starts with arterial endothelium injury causing inflammation. This inflammation triggers the formation of foam cells by macrophages consuming low-density lipoprotein (LDL). Subsequently, smooth muscle grows over fatty streaks, creating fibrous plaques. Therefore, option D is the correct answer. Choices A, B, and C are incorrect because they do not reflect the accurate chronological order of events in the pathogenesis of atherosclerosis.

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