Nursing Elites

1. Which of the following diseases or disorders is acute?

• A. Pneumonia
• B. Paralysis
• C. Alzheimer's disease
• D. Diabetes

Correct answer: A

Rationale: The correct answer is Pneumonia. Pneumonia is an acute illness characterized by inflammation of the air sacs in the lungs. It comes on suddenly and typically lasts for a short duration. Treatment can help cure pneumonia. Paralysis, Alzheimer's disease, and Diabetes are chronic conditions. Paralysis is the loss of muscle function in part of the body, usually permanent. Alzheimer's disease is a progressive brain disorder leading to memory loss and cognitive decline, and it is incurable. Diabetes is a chronic condition that affects how your body turns food into energy, and it requires lifelong management. Therefore, Pneumonia is the only acute condition among the options provided.

2. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?

• A. Document the presence of continuous bubbling.
• B. Notify the surgeon of a possible pneumothorax.
• C. Take no further action with the collection device.
• D. Adjust the dial on the wall regulator to decrease suction.

Correct answer: C

Rationale: Continuous bubbling in the suction-control chamber of the chest tube collection device is an expected finding and indicates that the suction control chamber is connected to suction. It does not necessarily indicate a large air leak, which would be detected in the water-seal chamber. There is no evidence to suggest a pneumothorax based solely on continuous bubbling in the suction-control chamber. Adjusting the suction level by changing the wall regulator setting is not indicated in this situation, as the amount of suction applied is primarily regulated by the water level in the water-seal chamber and not by the vacuum source. Therefore, the most appropriate action in this scenario is for the nurse to take no further action with the collection device.

3. Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?

• A. Teach the patient to avoid using over-the-counter expectorants.
• B. Assist the patient with chest physiotherapy and postural drainage.
• C. Notify the healthcare provider immediately regarding any bloody or foul-smelling sputum.
• D. Teach about the necessity of prolonged antibiotic therapy after discharge from the hospital.

Correct answer: D

Rationale: For a patient diagnosed with a lung abscess, the priority intervention is to educate them about the importance of prolonged antibiotic therapy post-hospital discharge. Long-term antibiotic treatment is crucial for eradicating the infecting organisms in a lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess as they can potentially spread the infection. While foul-smelling and bloody sputum are common in lung abscess, immediate notification to the healthcare provider is essential. Avoiding the use of over-the-counter expectorants is not necessary, as expectorants can be used to facilitate coughing and clearing of secretions in this condition.

4. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?

• A. INR is 3 seconds long
• B. Heart rate is 110 beats per minute
• C. Intracranial Pressure is 22 mmHg
• D. Blood pressure is 140/80

Correct answer: C

Rationale: The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.

5. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:

• A. Increase fluids that are high in protein
• B. Restrict fluids
• C. Force fluids and reassess blood pressure
• D. Limit fluids to non-caffeine beverages

Correct answer: D

Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability. Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.

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