Nursing Elites

1. What lab value should be monitored in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Serum albumin levels
• C. Hemoglobin levels
• D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A CD4 T-cell count below 180 cells/mm3 signifies severe immunosuppression and an increased risk of opportunistic infections. Serum albumin levels (choice B) are important for nutritional status assessment but not specific to HIV monitoring. Hemoglobin levels (choice C) are important for assessing anemia but do not directly reflect HIV disease progression. White blood cell count (choice D) is a general marker of inflammation and infection, but monitoring CD4 T-cell count is more specific and crucial in managing HIV.

2. What should the nurse do for a patient experiencing abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. This action helps relieve the cramping by slowing down the flow of the solution. Choice B, stopping the procedure and removing the tubing, is incorrect as it is too drastic and may not address the cramping. Choice C, continuing the enema at a slower rate, may exacerbate the cramping if the flow rate is still too high. Choice D, increasing the flow of the enema solution, would worsen the cramping and is not the appropriate intervention.

3. A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should not wash my hair prior to the procedure.
• B. I will receive a sedative 1 hour before the procedure.
• C. I should avoid eating prior to the procedure.
• D. I will be exposed to flashes of light during the procedure.

Correct answer: D

Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.

4. What teaching should be provided to a patient following surgical removal of a cataract?

• A. Avoid NSAIDs
• B. Wear dark glasses while outdoors
• C. Creamy white drainage is normal
• D. Reduce phosphorus intake to 700 mg/day

Correct answer: A

Rationale: The correct teaching to provide to a patient following surgical removal of a cataract is to avoid NSAIDs. NSAIDs can increase the risk of bleeding at the surgical site, so it is important to steer clear of them. Choice B, wearing dark glasses while outdoors, may be recommended post-surgery to protect the eyes from bright light, but it is not the priority teaching in this case. Choice C, stating that creamy white drainage is normal, is not accurate as drainage from the eye should be monitored and reported. Choice D, reducing phosphorus intake to 700 mg/day, is unrelated to post-cataract surgery care and is not a necessary teaching point.

5. What should the healthcare provider do first when a patient is admitted with chest pain and possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Get IV access
• C. Auscultate heart sounds
• D. Obtain cardiac enzymes

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority intervention when a patient presents with chest pain and suspected acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. It is crucial to address the pain and potential ischemia promptly to prevent further cardiac tissue damage. Getting IV access, auscultating heart sounds, and obtaining cardiac enzymes are important assessments and interventions, but administering nitroglycerin takes precedence in managing acute coronary syndrome.

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