Nursing Elites

1. Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

• A. Potential complication: seizures
• B. Potential complication: infection
• C. Potential complication: neurogenic shock
• D. Potential complication: pulmonary edema

Correct answer: B

Rationale: The correct answer is B: Potential complication: infection. Patients with idiopathic aplastic anemia have pancytopenia, which puts them at a high risk for infections due to decreased production of all blood cells (red blood cells, white blood cells, and platelets). Infection is a significant concern in these patients. Choices A, C, and D are incorrect because seizures, neurogenic shock, and pulmonary edema are not typically associated with idiopathic aplastic anemia. While seizures can occur in some conditions that affect the brain, neurogenic shock is related to spinal cord injury, and pulmonary edema is more commonly seen in conditions like heart failure.

2. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

• A. I will call my health care provider if my stools turn black.
• B. I will take a stool softener if I feel constipated occasionally.
• C. I should take the iron with orange juice about an hour before eating.
• D. I should increase my fluid and fiber intake while I am taking iron tablets.

Correct answer: A

Rationale: It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this.

3. During a physical assessment, the nurse examines the lymph nodes of a patient. Which assessment finding would be of most concern to the nurse?

• A. A 2-cm nontender supraclavicular node
• B. A 1-cm mobile and nontender axillary node
• C. An inability to palpate any superficial lymph nodes
• D. Firm inguinal nodes in a patient with an infected foot

Correct answer: A

Rationale: The correct answer is A. A 2-cm nontender supraclavicular node is of most concern because enlarged and nontender nodes in this area are highly suggestive of malignancies such as lymphoma. Choice B is less concerning as a 1-cm mobile and nontender axillary node is usually benign. Choice C, an inability to palpate any superficial lymph nodes, could be due to factors like obesity or edema, but it is not necessarily a cause for immediate concern. Choice D, firm inguinal nodes in a patient with an infected foot, may indicate a local reaction to infection rather than a systemic issue related to malignancy.

4. The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?

• A. Yellow-tinged sclerae
• B. Shiny, smooth tongue
• C. Numbness of the extremities
• D. Gum bleeding and tenderness

Correct answer: C

Rationale: The correct answer is C: Numbness of the extremities. Numbness of the extremities is a common finding in patients with pernicious anemia, which is caused by cobalamin (vitamin B12) deficiency. This deficiency affects the peripheral nervous system, leading to neurological symptoms like numbness and tingling in the extremities. Choices A, B, and D are incorrect: Yellow-tinged sclerae is more indicative of jaundice or liver dysfunction, a shiny smooth tongue is seen in conditions like glossitis, and gum bleeding and tenderness are associated with periodontal disease or vitamin C deficiency, not pernicious anemia.

5. The nurse is caring for a patient post-coronary artery bypass graft procedure who is on a nitroglycerin intravenous drip. The nurse understands the importance of nitroglycerin with this procedure as:

• A. Decreasing myocardial oxygen supply.
• B. Increasing preload.
• C. Decreasing cardiac output.
• D. Decreasing afterload.

Correct answer: D

Rationale: Nitroglycerin is a vasodilator that works by decreasing afterload, which is the pressure the heart must work against to eject blood during systole. By reducing afterload, nitroglycerin helps the heart pump more effectively and decreases the workload on the heart. This results in improved cardiac output and decreased myocardial oxygen demand. Choices A, B, and C are incorrect because nitroglycerin does not decrease myocardial oxygen supply, increase preload, or decrease cardiac output.

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