Nursing Elites

1. Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?

• A. Increase activity level.
• B. Maintain adequate nutrition
• C. Establish a stable environment
• D. Identify sources of hepatitis exposure

Correct answer: B

Rationale: The highest priority outcome is to maintain adequate nutrition because it is essential for hepatocyte regeneration. In viral hepatitis, the liver is affected, and proper nutrition supports the liver's function and regeneration. While increasing activity level and establishing a stable environment are important, they are not as urgent as ensuring the patient receives proper nutrition. Identifying sources of hepatitis exposure can help prevent future infections, but in the acute phase, the immediate focus should be on providing adequate nutrition to support the patient's recovery.

2. A 65-year-old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia. The patient lives in an upstairs apartment. The nurse is most concerned about which side effect of Flomax?

• A. Hypotension
• B. Tachycardia
• C. Back Pain
• D. Difficulty Urinating

Correct answer: A

Rationale: The correct answer is 'Hypotension.' Flomax (Tamsulosin) is known to cause orthostatic hypotension, especially in the elderly, leading to a sudden drop in blood pressure when standing up. This side effect can result in dizziness, falls, and injury, especially concerning for a patient living in an upstairs apartment. Tachycardia (increased heart rate) and back pain are less commonly associated with Flomax use, while difficulty urinating is a symptom that Flomax is intended to improve in patients with Benign Prostatic Hyperplasia.

3. The patient is being taught about pulmonary function testing (PFT). Which statement made by the patient indicates effective teaching?

• A. I will use my inhaler right before the test.
• B. I won't eat or drink anything 8 hours before the test.
• C. I should inhale deeply and blow out as hard as I can during the test.
• D. My blood pressure and pulse will be checked every 15 minutes after the test.

Correct answer: C

Rationale: The correct answer is 'I should inhale deeply and blow out as hard as I can during the test.' This statement indicates effective teaching because for PFT, the patient needs to inhale deeply and exhale forcefully. This maneuver helps in assessing lung function accurately. Choices A, B, and D are incorrect. Using an inhaler right before the test may alter the test results, which is not recommended. Fasting for 8 hours is not necessary for a PFT, and checking blood pressure and pulse every 15 minutes after the test is not part of the PFT procedure.

4. 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.

5. What nursing action demonstrates the nurse understands the priority nursing diagnosis when caring for patients being treated with splints, casts, or traction?

• A. The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
• B. The nurse orders meals with adequate protein and calcium for the patient.
• C. The nurse teaches the patient never to insert objects under a cast to scratch an itch.
• D. The nurse administers oral painkillers as ordered.

Correct answer: A

Rationale: The correct answer is to assess extremity pulse, temperature, color, pain, and feeling every hour. This action aligns with the priority nursing diagnosis of Risk for Peripheral Neurovascular Dysfunction related to fractures. Monitoring these factors is crucial to detect any signs of compromised circulation or nerve function promptly. Option B is incorrect as it does not directly address the priority nursing diagnosis. Option C is important but does not directly relate to the neurovascular aspect. Option D, administering painkillers, is necessary but does not specifically address the priority nursing diagnosis of neurovascular dysfunction.

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