Nursing Elites

1. The client is seven (7) days post total hip replacement. Which statement by the client requires the nurse's immediate attention?

• A. I have bad muscle spasms in my lower leg of the affected extremity.
• B. I just can't 'catch my breath' over the past few minutes and I think I am in grave danger.
• C. I have to use the bedpan to pass my water at least every 1 to 2 hours.
• D. It seems that the pain medication is not working as well today.

Correct answer: B

Rationale: While all statements by the client require attention, the most critical one that demands immediate action is option B. Clients who have undergone hip or knee surgery are at an increased risk of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are hallmark signs of this condition. Without appropriate prophylaxis such as anticoagulant therapy, deep vein thrombosis (DVT) can develop within 7 to 14 days after surgery, potentially leading to pulmonary embolism. It is crucial for the nurse to recognize signs of DVT, which include pain, tenderness, skin discoloration, swelling, or tightness in the affected leg. Signs of pulmonary embolism include sudden onset dyspnea, tachycardia, confusion, and pleuritic chest pain. Option B indicates a potentially life-threatening situation that requires immediate intervention to prevent serious complications.

2. What drives respiration in a patient with advanced chronic respiratory failure?

• A. Hypoxemia
• B. Hypocapnia
• C. Hypercapnia
• D. None of the above

Correct answer: A

Rationale: In patients with advanced chronic respiratory failure, such as those with chronic obstructive pulmonary disease (COPD), the respiratory drive shifts from being primarily stimulated by high levels of carbon dioxide (hypercapnia) to being driven by low oxygen levels (hypoxemia). This shift is due to the body's adaptation to chronic respiratory acidosis and hypoxemia. As a result, hypoxemia becomes the primary stimulus for respiration in these patients. Hypocapnia, a low level of carbon dioxide, is not a common driver of respiration in patients with advanced chronic respiratory failure. Therefore, the correct answer is hypoxemia.

3. The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

• A. Diarrhea
• B. Projectile vomiting
• C. Regurgitation of feedings
• D. Constipation

Correct answer: C

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is characterized by the absence of ganglion cells in the rectum and other parts of the affected intestine. Clinical manifestations of Hirschsprung's disease include chronic constipation with pellet-like or ribbon-like foul-smelling stools, delayed or absent passage of meconium in the neonatal period, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive. In the case of an infant with suspected Hirschsprung's disease, regurgitation of feedings is a sign that may have led the mother to seek healthcare. This symptom can be associated with the bowel dysfunction and obstruction seen in Hirschsprung's disease. Options A, B, and D are not typically associated with Hirschsprung's disease. Diarrhea is not a common symptom, projectile vomiting is not a typical presentation, and constipation, while a symptom of the disease, is not the sign that would most likely prompt a visit to seek healthcare in an infant suspected of having Hirschsprung's disease.

4. A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?

• A. Do not let this prescription run out.
• B. The medication may cause gingival hyperplasia.
• C. Periodic serum drug levels are needed.
• D. Watch for excessive facial hair growth.

Correct answer: A

Rationale: The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.

5. Septic, anaphylactic, and neurogenic shock are all categorized as:

• A. Hypovolemic shock
• B. Cardiogenic shock
• C. Distributive shock
• D. Obstructive shock

Correct answer: C

Rationale: Septic, anaphylactic, and neurogenic shock are all types of distributive shock. Distributive shock is characterized by a decrease in systemic vascular resistance, leading to poor tissue perfusion. Septic shock is caused by severe infection, anaphylactic shock is an extreme allergic reaction, and neurogenic shock results from damage to the nervous system. Hypovolemic shock (Choice A) is characterized by a decrease in intravascular volume, cardiogenic shock (Choice B) is due to heart failure, and obstructive shock (Choice D) results from obstruction of blood flow. Therefore, the correct categorization for septic, anaphylactic, and neurogenic shock is distributive shock.

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