Nursing Elites

1. Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?

• A. Advise limiting alcohol intake to 1 drink daily
• B. Schedule for liver cancer screening every 6 months
• C. Initiate administration of the hepatitis C vaccine series
• D. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually

Correct answer: B

Rationale: Patients diagnosed with chronic hepatitis B are at a higher risk for developing liver cancer. Therefore, it is essential to schedule them for liver cancer screening every 6 to 12 months to detect any potential malignancies at an early stage. Advising patients to limit alcohol intake is crucial as alcohol can exacerbate liver damage; thus, patients with chronic hepatitis B are advised to completely avoid alcohol. Administering the hepatitis C vaccine is irrelevant for a patient diagnosed with chronic hepatitis B since it is a different virus. Monitoring anti-hepatitis B surface antigen (anti-HBs) levels annually is not necessary as the presence of anti-HBs indicates a past hepatitis B infection or vaccination, and it does not require regular monitoring.

2. The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

• A. Diarrhea
• B. Projectile vomiting
• C. Regurgitation of feedings
• D. Constipation

Correct answer: C

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is characterized by the absence of ganglion cells in the rectum and other parts of the affected intestine. Clinical manifestations of Hirschsprung's disease include chronic constipation with pellet-like or ribbon-like foul-smelling stools, delayed or absent passage of meconium in the neonatal period, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive. In the case of an infant with suspected Hirschsprung's disease, regurgitation of feedings is a sign that may have led the mother to seek healthcare. This symptom can be associated with the bowel dysfunction and obstruction seen in Hirschsprung's disease. Options A, B, and D are not typically associated with Hirschsprung's disease. Diarrhea is not a common symptom, projectile vomiting is not a typical presentation, and constipation, while a symptom of the disease, is not the sign that would most likely prompt a visit to seek healthcare in an infant suspected of having Hirschsprung's disease.

3. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?

• A. Double the birth weight
• B. Triple the birth weight
• C. Gain 6 ounces each week
• D. Add 2 pounds each month

Correct answer: A

Rationale: Infants typically double their birth weight by 6 months of age as part of normal growth and development. This doubling of weight is a common milestone used by healthcare providers to assess a baby's growth progress. Tripling the birth weight or adding 2 pounds each month would result in excessive weight gain, which is not typical or healthy for an infant. Similarly, gaining 6 ounces each week would also lead to rapid and abnormal weight gain, making it an incorrect choice.

4. A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry indicates that the O2 saturation is 94%. Which action should the nurse take next?

• A. Administer bicarbonate.
• B. Complete a head-to-toe assessment.
• C. Place the patient on high-flow oxygen.
• D. Obtain repeat arterial blood gases (ABGs).

Correct answer: C

Rationale: In a patient with metabolic alkalosis and an O2 saturation of 94%, placing the patient on high-flow oxygen is the correct action. Even though the O2 saturation seems adequate, metabolic alkalosis causes a left shift in the oxyhemoglobin dissociation curve, reducing oxygen delivery to tissues. Therefore, providing high-flow oxygen can help compensate for this. Administering bicarbonate would exacerbate the alkalosis. While completing a head-to-toe assessment and obtaining repeat ABGs are important interventions, the priority in this scenario is to improve oxygen delivery by placing the patient on high-flow oxygen.

5. A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

• A. Has increased airway obstruction
• B. Has improved airway obstruction
• C. Needs to be suctioned
• D. Exhibits hyperventilation

Correct answer: B

Rationale: The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.

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