Nursing Elites

1. Which of the following actions would be of highest priority with regards to the external shunt?

• A. Avoid taking blood pressure or blood sample from the arm with the shunt
• B. Instruct the patient not to exercise the arm with the shunt
• C. Heparinize the shunt daily
• D. Change the dressing of the shunt daily

Correct answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

2. In any event of an adverse hemolytic reaction during blood transfusion, Nursing intervention should focus on:

• A. Slow the infusion, Call the physician and assess the patient
• B. Stop the infusion, Assess the client, Send the remaining blood to the laboratory and call the physician
• C. Stop the infusion, Call the physician and assess the client
• D. Slow the confusion and keep a patent IV line open for administration of medication

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. A healthcare professional is reviewing the lab results of a client who has bulimia nervosa. The professional should notify the provider of which of the following results?

• A. White Blood Cells 5,200/mm³
• B. Hemoglobin 14 g/dL
• C. Magnesium 1.6 mg/dL
• D. Potassium 3.2 mEq/L

Correct answer: D

Rationale: A potassium level of 3.2 mEq/L is below normal and requires provider notification, especially in clients with bulimia nervosa who are at risk of electrolyte imbalances. Low potassium levels can lead to serious complications like cardiac arrhythmias. The other options are within or close to the normal range and would not be a priority for notification.

4. Which systolic blood pressure measurement is classified as prehypertension?

• A. 106 mmHg
• B. 119 mmHg
• C. 130 mmHg
• D. 141 mmHg

Correct answer: B

Rationale: According to the blood pressure classification, a systolic blood pressure between 120-139 mmHg is considered prehypertension. This range indicates an increased risk for developing hypertension if not managed appropriately. Therefore, a systolic blood pressure of 119 mmHg falls into the prehypertension category. A systolic pressure of 106 mmHg is within the normal range, while 130 mmHg and above would be classified as stage 1 and stage 2 hypertension respectively, not prehypertension.

5. Substance abuse is different from substance dependence in that, substance dependence:

• A. includes characteristics of adverse consequences and repeated use
• B. requires long term treatment in a hospital based program
• C. produces less severe symptoms than that of abuse
• D. includes characteristics of tolerance and withdrawal

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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