Nursing Elites

1. The infant has a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, what intervention should the nurse plan?

• A. Cover the bladder with petroleum jelly gauze.
• B. Cover the bladder with a non-adhering plastic wrap.
• C. Apply sterile distilled water dressings over the bladder mucosa.
• D. Keep the bladder tissue dry by covering it with dry sterile gauze.

Correct answer: C

Rationale: Bladder exstrophy is a condition where the bladder is exposed and external to the body. To protect the exposed bladder tissue from drying out while allowing urine drainage, it is best to cover the bladder with a non-adhering plastic wrap. Using petroleum jelly gauze should be avoided as it can dry out, adhere to the mucosa, and damage delicate tissue upon removal. Applying sterile distilled water dressings can also dry out and cause damage when removed. Keeping the bladder tissue dry with sterile gauze is not ideal as maintaining a moist environment is important for tissue protection in this case.

2. Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?

• A. The patient's urine is bright yellow
• B. The patient's stools are tan colored
• C. The patient has increased pain after eating
• D. The patient complains of chronic heartburn

Correct answer: B

Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.

3. Which of the following is TRUE about shock?

• A. A patient with severe shock does not always have an abnormally low blood pressure.
• B. Confusion and deteriorating mentation are indicative of hypotensive shock.
• C. Patients with compensated shock may not be able to maintain a normal blood pressure.
• D. A normal blood pressure does not imply that the patient is stable.

Correct answer: B

Rationale: Confusion and deteriorating mentation are indeed indicative of hypotensive shock. It is important to note that a patient with hypotensive shock will likely exhibit deteriorating mental status. Choice A is incorrect because a patient in severe shock may not always have an abnormally low blood pressure, making it an unreliable indicator of shock severity. Choice C is incorrect because patients with compensated shock may present with normal blood pressure but still have inadequate tissue perfusion. Choice D is incorrect because a normal blood pressure does not guarantee the patient's stability, especially in cases of shock where tissue perfusion may be compromised despite normal blood pressure readings.

4. A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?

• A. Slow, deep respirations
• B. Stridor
• C. Bradycardia
• D. Air hunger

Correct answer: D

Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (Choice A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (Choice B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (Choice C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.

5. When administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C, the nurse should monitor for which complication?

• A. Leukopenia.
• B. Hypokalemia.
• C. Polycythemia.
• D. Hypoglycemia.

Correct answer: B

Rationale: When administering a-interferon and ribavirin (Rebetol) for chronic hepatitis C, the nurse should monitor for hypokalemia. This combination therapy is known to cause leukopenia, not polycythemia or hypoglycemia. Hypokalemia is a common electrolyte imbalance that can occur with these medications, making it the correct answer to monitor for in this case.

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