Nursing Elites

1. What lab value should be prioritized for a patient with HIV?

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

Correct answer: A

Rationale: A CD4 T-cell count below 180 cells/mm3 should be prioritized for a patient with HIV. This value is crucial as it indicates severe immunocompromise in HIV-infected individuals. Monitoring CD4 T-cell count helps assess the status of the immune system and guides treatment decisions. Serum albumin levels (choice B) may reflect the patient's nutritional status and overall health but are not as specific to HIV disease progression. White blood cell count (choice C) and hemoglobin levels (choice D) can be affected by various factors and are not as directly linked to HIV management as the CD4 T-cell count in this context.

2. What should the healthcare provider do if a patient presents with chest pain and possible acute coronary syndrome?

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

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority action in the treatment of chest pain in acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain. Aspirin can also be given to reduce clot formation, but nitroglycerin takes precedence in providing immediate relief. Obtaining cardiac enzymes and assessing heart sounds are important steps in the diagnostic process but do not address the immediate need to relieve chest pain and prevent cardiac tissue damage. Therefore, administering sublingual nitroglycerin is the most appropriate initial intervention for a patient presenting with chest pain and possible acute coronary syndrome.

3. When caring for a patient with a burn injury, what is the priority intervention?

• A. Monitor the burn area for infection
• B. Administer IV fluids
• C. Debride the burn area
• D. Apply a dry dressing

Correct answer: A

Rationale: The priority intervention when caring for a patient with a burn injury is to monitor the burn area for infection. This is crucial to prevent further complications such as sepsis. While administering IV fluids is important for fluid resuscitation, it is not the top priority compared to preventing infection. Debriding the burn area and applying a dry dressing are necessary interventions for wound care, but ensuring there is no infection takes precedence to avoid sepsis and other serious complications.

4. What are the signs and symptoms of Increased Intracranial Pressure (IICP)?

• A. Irritability, confusion, restlessness
• B. Fatigue and SOB
• C. Changes in pupillary response
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Irritability, confusion, restlessness. These are common signs of Increased Intracranial Pressure (IICP) as they result from the increased pressure on brain tissue. Choices B, C, and D are incorrect. Fatigue and shortness of breath (SOB) are not typical symptoms of IICP. Changes in pupillary response can be seen in other conditions but are not specific to IICP. Elevated blood pressure is not a common sign of IICP.

5. What teaching should be provided to a patient following an escharotomy for burn injuries?

• A. Monitor for infection
• B. Restrict fluid intake
• C. Avoid physical activity
• D. Limit phosphorus to 1,500 mg/day

Correct answer: A

Rationale: Following an escharotomy for burn injuries, patients should be taught to monitor for infection and care for the incision site. Choice A is the correct answer because infection is a common risk after a procedure involving incisions. Choices B, C, and D are incorrect. Restricting fluid intake is not typically advised after an escharotomy; avoiding physical activity may vary depending on the individual's condition and should be guided by healthcare providers; and limiting phosphorus to 1,500 mg/day is not directly related to post-escharotomy care.

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