Nursing Elites

1. The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?

• A. Morning headaches
• B. Pain for 3 consecutive months
• C. Febrile episodes in the late afternoon
• D. Diaphoresis when attacks occur

Correct answer: B

Rationale: The correct answer is B: Pain for 3 consecutive months. Recurrent abdominal pain (RAP) is characterized by abdominal pain that occurs at least once per week for at least 2 months before diagnosis. Choosing option A is incorrect since morning headaches are not a common characteristic of RAP. Option C is incorrect because febrile episodes in the late afternoon are not typically associated with RAP. Option D is incorrect as diaphoresis (excessive sweating) when attacks occur is not a common finding in RAP.

2. A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

• A. Low oxygen levels are present in the blood.
• B. High levels of carbon dioxide have accumulated in the blood.
• C. Increased bicarbonate levels are causing alkalosis.
• D. Respiratory rate is increased, causing hyperventilation.

Correct answer: B

Rationale: High levels of carbon dioxide in the blood lead to respiratory acidosis due to inadequate ventilation. The correct answer is B. In respiratory acidosis, the accumulation of carbon dioxide in the blood occurs due to inadequate exhalation, leading to acidosis. Choice A is incorrect as low oxygen levels are related to hypoxemia, not respiratory acidosis. Choice C is incorrect as increased bicarbonate levels would lead to alkalosis, not acidosis. Choice D is incorrect as an increased respiratory rate causing hyperventilation would actually help decrease carbon dioxide levels, not lead to respiratory acidosis.

3. A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the perioperative nurse prepare to implement first?

• A. Ensure patency of an indwelling catheter and measure hourly intake and output.
• B. Prepare for cessation of the anesthesia and the surgical procedure.
• C. Obtain specimens of ABGs and serum electrolytes.
• D. Initiate cooling measures using iced normal saline by nasogastric lavage.

Correct answer: B

Rationale: The correct answer is B: Prepare for cessation of the anesthesia and the surgical procedure. Malignant hyperthermia is a severe reaction to certain medications used during general anesthesia. The immediate intervention to manage malignant hyperthermia is to stop the triggering agents, which include anesthesia and surgery. Ensuring patency of an indwelling catheter and measuring intake and output, obtaining specimens of ABGs and serum electrolytes, and initiating cooling measures are important interventions but should follow the immediate action of stopping the anesthesia and surgery to address the life-threatening condition of malignant hyperthermia.

4. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8°F, blood pressure 90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse assesses the client's findings, they include a mottled skin appearance and confusion. Which action should the nurse take first?

• A. Obtain a wound specimen for culture.
• B. Initiate an infusion of intravenous (IV) fluids.
• C. Transfer the client to the ICU.
• D. Assess the client's core temperature.

Correct answer: B

Rationale: The correct action for the nurse to take first is to initiate an infusion of intravenous (IV) fluids. In this scenario, the client is showing signs of sepsis, indicated by a high temperature, low blood pressure, rapid heart rate, and increased respiratory rate. Mottled skin appearance and confusion are also signs of poor perfusion. Initiating IV fluids is crucial in treating sepsis to maintain blood pressure and perfusion. Obtaining a wound specimen for culture (Choice A) can be important but is not the priority at this moment. Transferring the client to the ICU (Choice C) can be considered after stabilizing the client. Assessing the client's core temperature (Choice D) is not the immediate priority compared to addressing the signs of sepsis and poor perfusion.

5. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?

• A. Apply a cool compress to the affected fingers for 20 minutes
• B. Secure a pulse oximeter to monitor the client's oxygen saturation
• C. Report the finding to the healthcare provider as soon as possible
• D. Continue to monitor the fingers until the color returns to normal

Correct answer: D

Rationale: In primary Raynaud phenomenon, the fingers go through a color sequence of pallor, cyanosis, and then redness when warmed. The burning sensation reported by the client indicates reperfusion. Continuing to monitor the fingers until the color returns to normal is appropriate in this situation as it ensures that the symptoms are resolving without the need for further intervention. Applying a cool compress could exacerbate the symptoms by causing vasoconstriction. Securing a pulse oximeter to monitor oxygen saturation is not necessary in this case as the issue is related to vasospasm rather than oxygenation. Reporting the finding to the healthcare provider is not urgent unless there are signs of complications or the symptoms do not improve with warming.

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