Nursing Elites

1. When a healthcare professional observes muscle stiffening occurring within 6 to 14 hours after death, the healthcare professional should document this finding as _____ present.

• A. Livor mortis
• B. Gangrene
• C. Algor mortis
• D. Rigor mortis

Correct answer: D

Rationale: The correct answer is D, Rigor mortis. Rigor mortis is the stiffening of muscles after death, typically beginning within 6 to 14 hours. Livor mortis (choice A) refers to the pooling of blood in the lowest tissues causing discoloration, gangrene (choice B) is the death of body tissue due to lack of blood flow, and algor mortis (choice C) is the cooling of the body after death.

2. A patient is hospitalized due to nonadherence to an antitubercular drug treatment. Which of the following is most important for the nurse to do?

• A. Observe the patient taking the medications.
• B. Administer the medications parenterally.
• C. Instruct the family on the medication regimen.
• D. Count the number of tablets in the bottle daily.

Correct answer: A

Rationale: In this scenario, the most crucial action for the nurse to take is to observe the patient taking the medications. This ensures that the patient is actually consuming the prescribed antitubercular drugs, addressing the issue of nonadherence directly. Administering the medications parenterally (intravenously or intramuscularly) is not necessary unless there are specific medical reasons requiring this route of administration. Instructing the family on the medication regimen is important for support but may not directly address the patient's nonadherence. Counting the number of tablets in the bottle daily is not as effective as directly observing the patient taking the medications to ensure compliance.

3. Which of the following types of vitamin or mineral deficiency can cause megaloblastic anemia and is associated with lower extremity paresthesias?

• A. Vitamin B12
• B. Folate
• C. Iron
• D. Vitamin K

Correct answer: A

Rationale: The correct answer is Vitamin B12. Vitamin B12 deficiency can lead to megaloblastic anemia and neurological symptoms, including lower extremity paresthesias. Folate deficiency can also cause megaloblastic anemia but typically does not present with neurological symptoms. Iron deficiency leads to microcytic anemia, not megaloblastic anemia. Vitamin K deficiency is associated with coagulation abnormalities, not megaloblastic anemia.

4. A patient is receiving intravenous amphotericin. Which of the following assessments warrants the discontinuation of the antifungal agent?

• A. Sodium level of 138 mEq/L
• B. Hematocrit of 39%
• C. Blood urea nitrogen of 60 mg/dL
• D. AST level of 10 Unit/L

Correct answer: C

Rationale: Intravenous amphotericin can cause nephrotoxicity, leading to increased blood urea nitrogen levels. Elevated blood urea nitrogen (BUN) indicates impaired renal function, which is a known adverse effect of amphotericin. Therefore, a BUN level of 60 mg/dL warrants the discontinuation of the antifungal agent. The other options, such as a sodium level of 138 mEq/L, hematocrit of 39%, and AST level of 10 Unit/L, are within normal ranges and not indicative of the need to discontinue amphotericin therapy.

5. When educating a client about to undergo a pacemaker insertion, the nurse explains the normal phases of cardiac muscle tissue. During the repolarization phase, the nurse will stress that membranes must be repolarized before they can be re-excited. Within the cell, the nurse understands that:

• A. Potassium channels open while sodium channels close, causing repolarization to the resting state.
• B. The influx of calcium is the primary stimulus for the repolarization of cardiac tissue.
• C. Only the electrical activity within the heart will determine when repolarization occurs.
• D. The cell membranes need to stay calm, resulting in muscle tissue becoming refractory.

Correct answer: A

Rationale: During the repolarization phase of cardiac muscle tissue, potassium channels open while sodium channels close. This process is crucial for the cardiac muscle to return to its resting state after depolarization. Potassium moving out of the cell and sodium staying out helps reset the membrane potential and prepare the cell for the next depolarization phase. The influx of calcium is not the primary stimulus for repolarization in cardiac tissue; it is mainly involved in the depolarization phase. While electrical activity within the heart influences repolarization, the specific ion movements described in choice A are what physiologically drive repolarization. Cell membranes need to be in an active state during repolarization, not calm, to facilitate the necessary ion movements for muscle tissue to properly function.

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