Nursing Elites

1. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?

• A. Notify the healthcare provider of the findings.
• B. Ensure that the IV is infusing at the prescribed rate.
• C. Listen to lung sounds.
• D. Check under his back for evidence of bleeding.

Correct answer: D

Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.

2. The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

• A. Has everyone at home already had varicella?
• B. Have the antifungal creams been effective?
• C. Do your family members share combs and brushes?
• D. Do you have any dry patches on your feet and hands?

Correct answer: A

Rationale: The correct answer is A: 'Has everyone at home already had varicella?' Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. By knowing if others at home had varicella (chickenpox), the nurse can assess the risk of transmission and provide appropriate guidance. Choice B is incorrect because antifungal creams are not effective for herpes zoster, which is a viral infection. Choice C is irrelevant to herpes zoster as it pertains to sharing personal items that may transmit head lice or certain skin infections. Choice D is also unrelated as it focuses on dry patches, not typical manifestations of herpes zoster which presents as a painful rash.

3. When performing an assessment of a child with recurrent abdominal pain (RAP), what symptom is the child most likely to experience?

• A. Increased temperature
• B. Constipation
• C. Right quadrant pain
• D. Exercise-associated pain

Correct answer: B

Rationale: When assessing a child with recurrent abdominal pain (RAP), constipation is a common symptom. Children with RAP often experience periumbilical pain that is unrelated to eating, defecation, or exercise. While increased temperature, right quadrant pain, and exercise-associated pain can occur in various conditions, they are not typically associated with RAP in children.

4. When interacting with the parents of a SIDS infant, the nurse should attempt to assist the parents with:

• A. Encouraging the parents to have another baby.
• B. Encouraging the parents to remain stoic.
• C. Allaying feelings of guilt and blame.
• D. Learning how the event could have been prevented.

Correct answer: C

Rationale: The correct answer is C: Allaying feelings of guilt and blame. When parents experience the loss of a SIDS infant, they often struggle with intense feelings of guilt and self-blame. The nurse's role is to provide emotional support and help alleviate these feelings. Choices A and B are incorrect as encouraging the parents to have another baby or to remain stoic is not appropriate or helpful in this situation. Choice D is also incorrect because focusing on how the event could have been prevented may exacerbate feelings of guilt and is not the immediate priority in supporting grieving parents.

5. 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.

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