Nursing Elites

1. The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?

• A. Red man syndrome.
• B. Blood pressure of 130/80 mm Hg.
• C. Mild itching at the IV site.
• D. Nausea and vomiting.

Correct answer: A

Rationale: Red man syndrome is a severe and potentially life-threatening reaction to vancomycin characterized by flushing, rash, and hypotension. Immediate intervention is required to prevent further complications such as anaphylaxis. Therefore, the nurse should report this finding immediately to ensure prompt treatment and prevent serious adverse effects.

2. A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?

• A. A pattern of distinct exacerbations and remissions
• B. Severe diarrhea
• C. An absence of blood in stool
• D. Involvement of the rectal mucosa

Correct answer: C

Rationale: In the context of inflammatory bowel disease, the absence of blood in stool is more indicative of Crohn disease. Crohn disease typically presents with non-bloody stools, while ulcerative colitis often involves bloody stools due to continuous mucosal inflammation confined to the colon and rectum.

3. An otherwise healthy 45-year-old man presents with severe hematochezia and moderate abdominal cramping since this morning. A barium enema one year ago was normal. On examination, his blood pressure is 120/78 and pulse is 100 while lying; when standing, the blood pressure is 110/76 and pulse is 136. His hematocrit is 34. What is the most likely cause of bleeding?

• A. Diverticular bleed
• B. Duodenal ulcer
• C. Inflammatory bowel disease
• D. Vascular ectasia (watermelon stomach)

Correct answer: B

Rationale: The patient's presentation with hematochezia, moderate abdominal cramping, and hemodynamic changes (increased pulse on standing) suggests an upper gastrointestinal bleed. The drop in blood pressure and rise in pulse rate when standing indicate orthostatic hypotension, which is a sign of significant blood loss. The absence of melena does not rule out an upper GI bleed. Ulcers in the duodenal bulb can erode into the gastroduodenal artery, leading to brisk blood loss. A normal barium enema one year ago makes diverticular bleeding less likely. Inflammatory bowel disease usually does not cause severe acute GI bleeding unless there is ulceration into a vessel. Vascular ectasia, like watermelon stomach, typically presents with chronic blood loss and iron deficiency anemia, more common in older women. The absence of vomiting and the presence of hematochezia make Mallory-Weiss tear less likely in this case.

4. A client with a history of hypertension is prescribed lisinopril (Prinivil). Which side effect should the nurse monitor for?

• A. Dry cough.
• B. Weight gain.
• C. Tachycardia.
• D. Hyperglycemia.

Correct answer: A

Rationale: The correct answer is A: Dry cough. Lisinopril is an ACE inhibitor, and a common side effect of ACE inhibitors is a dry cough. This occurs due to the accumulation of bradykinin in the lungs, leading to irritation and subsequent cough. It is important for the nurse to monitor the client for this side effect as it can affect adherence to the medication regimen. Weight gain, tachycardia, and hyperglycemia are not typically associated with lisinopril. Therefore, choices B, C, and D are incorrect.

5. A client with cirrhosis of the liver is being cared for by the healthcare team. Which clinical manifestation indicates that the client has developed hepatic encephalopathy?

• A. Asterixis.
• B. Jaundice.
• C. Ascites.
• D. Splenomegaly.

Correct answer: A

Rationale: Asterixis, also known as flapping tremor, is a characteristic sign of hepatic encephalopathy, a severe complication of liver cirrhosis. Hepatic encephalopathy results from the liver's inability to detoxify substances in the body, leading to neurologic manifestations such as changes in mental status, confusion, and asterixis.

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