Nursing Elites

1. The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?

• A. Muscle tetany
• B. Syncope
• C. Numbness
• D. Anxiety

Correct answer: D

Rationale: The correct answer is 'Anxiety.' Anxiety is not a typical sign of right-sided heart failure. Right-sided heart failure usually presents with symptoms such as muscle tetany, syncope, and numbness. Muscle tetany can occur due to electrolyte imbalances seen in heart failure. Syncope can result from decreased cardiac output, leading to decreased perfusion to the brain. Numbness can occur due to poor circulation. While anxiety can be present in patients with various medical conditions, it is more commonly associated with respiratory acidosis or other psychological factors rather than right-sided heart failure.

2. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary

Correct answer: D

Rationale: This scenario describes early deceleration due to head compression, which is a benign finding in labor. Early decelerations mirror the contractions and do not require any intervention as they are considered a normal response to fetal head compression. The fetal heart rate returns to baseline at the end of the contraction. In this case, the correct action is no action at the moment. Close monitoring of the mother and baby is essential, but immediate intervention is not required. Administering O2 (Choice A) or turning the client on her left side (Choice B) is not indicated for early decelerations. Notifying the physician (Choice C) is unnecessary for this type of deceleration.

3. A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?

• A. Aspiration noted on a honey-thick diet
• B. Pain felt during a bowel movement
• C. Pain felt in the left upper quadrant
• D. Right shoulder pain

Correct answer: B

Rationale: The correct answer is 'Pain felt during a bowel movement.' Endoscopy is used to examine the upper gastrointestinal tract, which includes the esophagus, stomach, and duodenum. Pain during a bowel movement would suggest an issue in the lower gastrointestinal tract, which is typically examined with a colonoscopy. Choices A, C, and D are not probable reasons for an endoscopy procedure as they relate to symptoms in the upper gastrointestinal tract or are not specific to gastrointestinal issues. Aspiration noted on a honey-thick diet could indicate a risk of aspiration pneumonia related to swallowing difficulties, which can be assessed through an endoscopy. Pain felt in the left upper quadrant may be related to conditions like gastritis or peptic ulcers that can be investigated using an endoscopy. Right shoulder pain can be a referred pain from conditions like gallbladder disease that can also be evaluated with an endoscopy.

4. If a client is suffering from thyroid storm, the PN can expect to find on assessment:

• A. tachycardia and hyperthermia.
• B. bradycardia and hypothermia.
• C. a large goiter.
• D. a calm, quiet client

Correct answer: A

Rationale: In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed. Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter. Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.

5. Which of the following blood pressure parameters indicates PIH? Elevation over a baseline of:

• A. 30 mmHg systolic and/or 15 mmHg diastolic.
• B. 40 mmHg systolic and/or 20 mmHg diastolic.
• C. 10 mmHg systolic and/or 5 mmHg diastolic.
• D. 20 mmHg systolic and/or 20 mmHg diastolic.

Correct answer: A

Rationale: The correct answer is A: 30 mmHg systolic and/or 15 mmHg diastolic. These parameters indicate mild PIH (pregnancy-induced hypertension). Mild preeclampsia is characterized by an increase in systolic blood pressure greater than 30 mmHg or an increase in diastolic blood pressure greater than 15 mmHg, observed on two readings taken 6 hours apart (or reaching 140/90). Choice B (40 mmHg systolic and/or 20 mmHg diastolic) represents a more significant elevation and would indicate a more severe condition than mild PIH. Choices C (10 mmHg systolic and/or 5 mmHg diastolic) and D (20 mmHg systolic and/or 20 mmHg diastolic) do not meet the criteria for indicating PIH as they are below the accepted parameters for mild PIH.

Similar Questions