Nursing Elites

1. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

• A. Dry palpebral and oral mucosa
• B. Crackles at bilateral lung bases
• C. Temperature 100.8?F (38.2?C)
• D. No bowel movement for 4 days

Correct answer: C

Rationale: The correct answer is the patient's temperature of 100.8�F (38.2�C). In a patient who received a liver transplant 1 week ago, a fever is a significant finding that should be promptly communicated to the health care provider. Post-transplant patients are at high risk of infections, and fever can often be the initial indicator of an underlying infectious process. The other findings listed in choices A, B, and D are important and should be addressed, but they do not take precedence over a potential infection post-liver transplant. Dry palpebral and oral mucosa may indicate dehydration, crackles at bilateral lung bases may suggest fluid overload or infection, and no bowel movement for 4 days could indicate a bowel obstruction or ileus. However, in the context of a recent liver transplant, an elevated temperature is the most concerning and requires immediate attention to rule out infection.

2. A nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?

• A. Gestational age assessment suggested growth retardation
• B. Meconium was cleared from the airway at delivery
• C. Phototherapy was used to treat Rh incompatibility
• D. The infant received mechanical ventilation for 2 weeks

Correct answer: D

Rationale: The correct answer is 'The infant received mechanical ventilation for 2 weeks.' Bronchopulmonary dysplasia is a condition primarily caused by therapies like positive-pressure ventilation used in the treatment of lung disease. This leads to lung damage and subsequent respiratory problems. Choices A, B, and C are not consistent with the diagnosis of bronchopulmonary dysplasia. Gestational age assessment suggesting growth retardation is more indicative of intrauterine growth restriction, clearing meconium from the airway at delivery is related to potential respiratory issues at birth, and phototherapy for Rh incompatibility is unrelated to bronchopulmonary dysplasia.

3. What is the priority nursing diagnosis for a patient experiencing a migraine headache?

• A. Acute pain related to biologic and chemical factors
• B. Anxiety related to change in or threat to health status
• C. Hopelessness related to deteriorating physiological condition
• D. Risk for side effects related to medical therapy

Correct answer: A

Rationale: The priority nursing diagnosis for a patient experiencing a migraine headache is 'Acute pain related to biologic and chemical factors.' Migraine headaches are characterized by severe throbbing pain, often accompanied by sensitivity to light and sound. Addressing the acute pain is crucial to improve the patient's comfort and quality of life. Choices B, C, and D are not the priority nursing diagnoses for a patient with a migraine headache. Anxiety, hopelessness, and risk for side effects may not be as urgent as managing the acute pain associated with a migraine.

4. A client is being assessed for risks of a pressure ulcer by a healthcare professional. What is the best description of what may be found with an early pressure ulcer in an African American client?

• A. Skin has a purple/bluish color
• B. Capillary refill is 1 second
• C. Skin appears blanched at the pressure site
• D. Tenting appears when checking skin turgor

Correct answer: A

Rationale: When assessing for signs of developing pressure ulcers in a client with dark skin, traditional signs like blanching may not be evident. In individuals with darker skin tones, the skin of an early pressure ulcer may present with a purple or bluish hue. This discoloration can be a crucial indicator of compromised circulation and tissue damage. Capillary refill, blanching, and tenting are more commonly used in the assessment of skin integrity and hydration levels but may not be as reliable in individuals with darker skin tones, making the purple/bluish color a key finding in this context.

5. The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

• A. Observe for distended neck veins.
• B. Auscultate for crackles in the lungs.
• C. Palpate for heaves or thrills over the heart.
• D. Review hemoglobin and hematocrit values.

Correct answer: A

Rationale: To evaluate the effectiveness of therapies for cor pulmonale and right-sided heart failure, observing for distended neck veins would be the most appropriate assessment. Cor pulmonale is characterized by right ventricular failure due to pulmonary hypertension, leading to clinical manifestations such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness. These signs indicate increased central venous pressure and right heart strain, which can be assessed by observing for distended neck veins. Auscultating for crackles in the lungs is more indicative of left-sided heart failure rather than right-sided heart failure. Heaves or thrills over the heart are not typically associated with cor pulmonale. Reviewing hemoglobin and hematocrit values may show elevations due to chronic hypoxemia and polycythemia in cor pulmonale, but these values alone do not directly evaluate the immediate effectiveness of the prescribed therapies on the patient's condition.

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