Nursing Elites

1. The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?

• A. Check the BP every five minutes for one hour.
• B. Raise the HOB 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Take the client’s temperature using another method.

Correct answer: D

Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (Choice A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (Choice B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (Choice C) is a general intervention that may not directly address the specific concern of the low temperature reading.

2. A woman with chronic osteoarthritis is complaining of knee pain. Which pathophysiological process is contributing to her pain?

• A. Inflammation of the synovial membrane.
• B. Degeneration of the cartilage in the joint.
• C. Joint inflammation occurs when chondrocyte injury destroys joint cartilage, producing osteophytes.
• D. Formation of uric acid crystals in the joint space.

Correct answer: C

Rationale: The correct answer is C. In osteoarthritis, the breakdown of cartilage in the joints leads to chondrocyte injury, which results in the destruction of joint cartilage and the production of osteophytes. This process causes joint inflammation and pain. Choice A is incorrect because osteoarthritis primarily involves the articular cartilage rather than the synovial membrane. Choice B is incorrect as it describes the degeneration of cartilage but does not explain the specific pathophysiological process contributing to pain in osteoarthritis. Choice D is incorrect as the formation of uric acid crystals is characteristic of gout, not osteoarthritis.

3. In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. Intact skin with non-blanchable redness.
• C. Full-thickness tissue loss with visible fat.
• D. Full-thickness tissue loss with exposed bone, tendon, or muscle.

Correct answer: A

Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.

4. The nurse is caring for a client with acute pancreatitis. Which laboratory result is most indicative of this condition?

• A. Elevated serum amylase
• B. Decreased serum bilirubin
• C. Increased blood urea nitrogen (BUN)
• D. Decreased alkaline phosphatase

Correct answer: A

Rationale: Elevated serum amylase is the most indicative laboratory result of acute pancreatitis. In this condition, the pancreas becomes inflamed, leading to the leakage of amylase and lipase into the bloodstream. Elevated serum amylase levels are a classic finding in acute pancreatitis. Choices B, C, and D are not typically associated with acute pancreatitis. Decreased serum bilirubin, increased blood urea nitrogen (BUN), and decreased alkaline phosphatase levels are not specific markers for acute pancreatitis.

5. In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?

• A. Risk for infection.
• B. Risk for falls.
• C. Impaired skin integrity.
• D. Activity intolerance.

Correct answer: B

Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.

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