Nursing Elites

1. The nurse is providing postoperative care for a client who had a thyroidectomy. Which assessment finding requires immediate intervention?

• A. Hoarseness and weak voice
• B. Calcium level of 8.0 mg/dL (2.0 mmol/L)
• C. Heart rate of 110 beats per minute
• D. Difficulty swallowing

Correct answer: D

Rationale: Difficulty swallowing can indicate swelling or hematoma formation, which may compromise the airway and requires immediate intervention. Hoarseness and a weak voice are expected post-thyroidectomy due to manipulation of the laryngeal nerves but do not require immediate intervention. A calcium level of 8.0 mg/dL is within the normal range (8.5-10.5 mg/dL) and may not require immediate intervention. A heart rate of 110 beats per minute may be elevated due to stress or pain postoperatively, but it does not indicate an immediate threat to the airway.

2. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?

• A. Administer a prescribed sedative
• B. Encourage client to drink water
• C. Apply a high flow venturi mask
• D. Assist her to an upright position

Correct answer: D

Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.

3. Based on the interpretation of this strip, what action should be implemented first?

• A. Call a code.
• B. Start CPR.
• C. Administer IV fluids.
• D. Apply oxygen.

Correct answer: A

Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.

4. What is a causative factor of Hirschsprung disease?

• A. Frequent evacuation of solids, liquid, and gases
• B. Excessive peristaltic movement
• C. The absence of parasympathetic ganglion cells in a portion of the colon
• D. One portion of the bowel telescoping into another

Correct answer: C

Rationale: The correct answer is C: The absence of parasympathetic ganglion cells in a portion of the colon is a causative factor of Hirschsprung disease. This absence leads to the inability of the affected segment of the colon to relax, causing a functional obstruction. Choices A, B, and D are incorrect. Frequent evacuation of solids, liquid, and gases, excessive peristaltic movement, and one portion of the bowel telescoping into another are not causative factors of Hirschsprung disease.

5. What is the main characteristic of cystic fibrosis?

• A. Multiple upper respiratory infections
• B. An underproduction of exocrine glands
• C. Excessive, thick mucus
• D. An overproduction of thin mucus

Correct answer: C

Rationale: The main characteristic of cystic fibrosis is the production of excessive, thick mucus. This thick mucus leads to blockages in the airways, digestive system, and other organs. Choice A is incorrect because while individuals with cystic fibrosis are more prone to respiratory infections, the main characteristic is the mucus production. Choice B is incorrect as cystic fibrosis is characterized by the overproduction, not underproduction, of exocrine glands. Choice D is also incorrect as the mucus produced in cystic fibrosis is thick, not thin.

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