Nursing Elites

1. The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?

• A. Report the incident to the nursing supervisor.
• B. Write up a variance report about the incident.
• C. Instruct the students that this is a violation of HIPAA.
• D. Notify the students' faculty regarding the violation.

Correct answer: C

Rationale: The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.

2. For a client with suspected appendicitis, where should the nurse expect to find abdominal tenderness?

• A. upper right
• B. upper left
• C. lower right
• D. lower left

Correct answer: C

Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic symptom of appendicitis. This tenderness is known as McBurney's point, which is located in the lower-right quadrant of the abdomen. Choices A, B, and D are incorrect because the tenderness associated with appendicitis is typically localized to the lower-right quadrant.

3. A patient has fallen off a bicycle and fractured the head of the proximal fibula. A cast was placed on the patient's lower extremity. Which of the following is the most probable result of the fall?

• A. Peroneal nerve injury
• B. Tibial nerve injury
• C. Sciatic nerve injury
• D. Femoral nerve injury

Correct answer: A

Rationale: The correct answer is peroneal nerve injury. The head of the proximal fibula is in close proximity to the peroneal nerve, making it susceptible to injury when there is a fracture. The peroneal nerve runs along the fibula and can be affected by trauma to this area. Choice B, tibial nerve injury, is incorrect as the fracture site is closer to the peroneal nerve, not the tibial nerve. Choice C, sciatic nerve injury, is incorrect as the injury is more localized to the fibular head area where the peroneal nerve is affected. Choice D, femoral nerve injury, is incorrect as the femoral nerve is not immediately adjacent to the proximal fibula and is not typically affected by this type of injury.

4. The nurse is caring for a client admitted with Class III/IV Pulmonary Hypertension. The nurse explains to the client that Lanoxin is being administered to the client in order to:

• A. Manage peripheral edema
• B. Improve right ventricular function
• C. Increase pulmonary pressure
• D. Constrict the pulmonary vessels

Correct answer: B

Rationale: The correct answer is to improve right ventricular function. Lanoxin, also known as digoxin, is a cardiac glycoside that works by slowing the heart rate and increasing myocardial contractility, especially in the ventricles. This action helps improve the efficiency of the heart's pumping function, particularly the right ventricle in conditions like pulmonary hypertension. Choice A, managing peripheral edema, is not directly related to Lanoxin's mechanism of action. Choice C, increasing pulmonary pressure, is incorrect as Lanoxin is not used to increase pressure in the pulmonary circulation. Choice D, constricting the pulmonary vessels, is incorrect as Lanoxin does not cause vasoconstriction in the pulmonary vessels but rather acts on the heart's contractility.

5. The client with peripheral vascular disease is reviewing self-care measures. Which of the following statements indicates proper self-care measures?

• A. "I like to soak my feet in the hot tub every day."?
• B. "I walk to the mailbox in my bare feet."?
• C. "I stopped smoking and only use chewing tobacco."?
• D. "I have my wife examine the soles of my feet each day."?

Correct answer: D

Rationale: The correct answer is, "I have my wife examine the soles of my feet each day."? Clients with peripheral vascular disease should examine their feet daily for any signs of redness, dryness, or cuts. If the client is unable to do this themselves due to decreased sensation in their feet, a caregiver or family member should assist. Soaking feet in a hot tub should be avoided as the client may not be able to sense if the water is too hot, potentially causing burns. Walking barefoot can lead to injuries, so wearing shoes or slippers is recommended to minimize trauma. While quitting smoking is a positive step, using chewing tobacco can still constrict blood vessels, adversely affecting circulation in the extremities.

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