Nursing Elites

1. What are the final factors that contribute to blood pressure? (Select all that apply)

• A. Heart rate
• B. Stroke volume
• C. Peripheral resistance
• D. Neuroendocrine hormones

Correct answer: D

Rationale: Neuroendocrine hormones play a crucial role in regulating blood pressure by influencing factors like fluid balance, blood volume, and vessel constriction. While heart rate, stroke volume, and peripheral resistance are important factors affecting blood pressure, the final parameters that directly produce blood pressure are influenced by neuroendocrine hormones. Therefore, choice D is the correct answer. Choices A, B, and C are involved in the regulation of blood pressure but are not the final parameters that directly produce it.

2. A client with a diagnosis of depression is prescribed an SSRI. What is the most important information the nurse should provide?

• A. Take the medication as prescribed.
• B. Avoid consuming grapefruit juice.
• C. Report any thoughts of self-harm immediately.
• D. Understand that improvement may take weeks.

Correct answer: C

Rationale: The most important information the nurse should provide to a client prescribed an SSRI for depression is to report any thoughts of self-harm immediately. SSRIs can increase suicidal ideation, especially at the beginning of treatment, so it is crucial to monitor for this and take appropriate actions. While it is important to take the medication as prescribed (Choice A), the immediate need for reporting self-harm ideation takes precedence. Avoiding grapefruit juice (Choice B) is a general precaution with certain medications but not as critical in this scenario. Understanding that improvement may take weeks (Choice D) is important for managing treatment expectations, but ensuring the client's safety in the context of suicidal ideation is the top priority.

3. The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area?

• A. Duodenum
• B. Gastric pylorus
• C. Liver
• D. Spleen

Correct answer: C

Rationale: The correct answer is C: Liver. The liver is located in the right upper hypochondriac region of the abdomen. The duodenum (Choice A) is located in the right upper quadrant but not directly underneath the right upper hypochondriac region. The gastric pylorus (Choice B) is part of the stomach and is located more centrally in the abdomen. The spleen (Choice D) is located in the left upper quadrant of the abdomen, not underneath the right upper hypochondriac region.

4. A client is admitted with a diagnosis of pneumonia. Which intervention should the nurse implement to promote airway clearance?

• A. Administer bronchodilators as prescribed.
• B. Encourage increased fluid intake.
• C. Perform chest physiotherapy.
• D. Provide humidified oxygen.

Correct answer: B

Rationale: Encouraging increased fluid intake is the most appropriate intervention to promote airway clearance in a client with pneumonia. Adequate hydration helps to thin respiratory secretions, making it easier for the client to cough up and clear the airways. Administering bronchodilators (Choice A) may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy (Choice C) can be beneficial in certain cases but may not be the initial intervention for promoting airway clearance. Providing humidified oxygen (Choice D) can help improve oxygenation but does not specifically target airway clearance in pneumonia.

5. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child?

• A. Use sunblock or protective clothing when outdoors.
• B. Include the child in regular outings with the family.
• C. Obtain any childhood vaccinations that are not up-to-date.
• D. Use diluted commercial mouthwash for mouth care.

Correct answer: A

Rationale: The correct answer is to use sunblock or protective clothing when outdoors. Methotrexate can cause photosensitivity, making the child more prone to sunburns and skin damage. Therefore, advising the parents to protect their child's skin from direct sunlight exposure is crucial. Choice B is incorrect because exposing the child to direct sunlight without protection can worsen the photosensitivity caused by methotrexate. Choice C is incorrect as obtaining vaccinations is generally avoided during chemotherapy due to the child's compromised immune system. Choice D is incorrect as commercial mouthwash may contain alcohol, which can be irritating to the child's oral mucosa, especially during chemotherapy.

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