Nursing Elites

1. Which of the following findings is commonly associated with congestive heart failure?

• A. Decreased jugular venous pressure
• B. Pulmonary edema
• C. Hyperactive bowel sounds
• D. Weight loss

Correct answer: B

Rationale: Pulmonary edema is a common finding in congestive heart failure. In congestive heart failure, the heart is unable to pump effectively, leading to fluid buildup in the lungs, causing pulmonary edema. This results in symptoms like shortness of breath, coughing, and wheezing. Choices A, C, and D are not typically associated with congestive heart failure. Jugular venous pressure is often elevated, not decreased in heart failure. Hyperactive bowel sounds and weight loss are not specific findings for congestive heart failure.

2. Which of the following steps occurs first during hemostasis?

• A. Vascular spasm
• B. Platelet plug
• C. Coagulation
• D. Dissolution of the clot

Correct answer: A

Rationale: Vascular spasm is the initial step in hemostasis, where blood vessels constrict to reduce blood flow to the injured area. This constriction helps limit blood loss until further steps like platelet plug formation and coagulation can take place. Platelet plug formation and coagulation occur after the vascular spasm, making them incorrect choices. Dissolution of the clot happens much later in the healing process, after the injury has sufficiently healed.

3. A client with atrial fibrillation is at risk for which of the following complications?

• A. Deep vein thrombosis (DVT)
• B. Pulmonary embolism
• C. Hypertensive crisis
• D. Myocardial infarction

Correct answer: B

Rationale: Corrected Rationale: A client with atrial fibrillation is at increased risk of thromboembolism due to blood stasis in the atria. This can lead to the formation of blood clots, which may travel to the lungs and cause a pulmonary embolism. Pulmonary embolism is a serious complication of atrial fibrillation. Choices A, C, and D are incorrect because while atrial fibrillation can lead to complications such as stroke or heart failure, it is specifically associated with an increased risk of pulmonary embolism due to the clot formation associated with the condition.

4. A nurse working in a busy orthopedic clinic is asked to perform the Tinel sign on a client having problems in her hand/wrist. In order to test Tinel sign, the nurse should give the client which direction?

• A. Stand tall, arms at your side, shut your eyes; place the tip of your index finger to your nose.
• B. Hold your wrist in complete flexion, keep it in this position for 60 seconds. How does your hand feel after placing it in a neutral position?
• C. I'm going to tap (percuss) over the median nerve in your wrist; tell me what sensation you feel while I am doing this. Does the sensation stay in the wrist or go anywhere else?
• D. I'm going to tap this tuning fork; place it on the side of your thumb, then tell me what you are feeling in your hand and wrist.

Correct answer: C

Rationale: The correct answer is C. The Tinel sign involves percussing over the median nerve in the wrist to test for carpal tunnel syndrome. Choice A is incorrect as it describes a different action unrelated to the Tinel sign. Choice B is also incorrect as it involves holding the wrist in flexion, which is not part of the Tinel sign assessment. Choice D is incorrect as it mentions using a tuning fork on the thumb, which is not the correct technique for assessing the Tinel sign.

5. A patient with endometriosis is prescribed medroxyprogesterone acetate (Provera). What should the nurse include in the patient education?

• A. Medroxyprogesterone should be taken at the same time each day to maintain consistent hormone levels.
• B. Medroxyprogesterone can be taken with food to reduce gastrointestinal upset.
• C. Medroxyprogesterone should be discontinued if side effects occur.
• D. Medroxyprogesterone should be taken once a week to maintain effectiveness.

Correct answer: A

Rationale: When educating a patient with endometriosis who is prescribed medroxyprogesterone acetate (Provera), the nurse should emphasize the importance of taking the medication at the same time each day. This helps maintain consistent hormone levels and ensures the effectiveness of the treatment. Option A is correct. Option B is incorrect because medroxyprogesterone should be taken consistently, regardless of food intake. Option C is incorrect because discontinuing the medication without consulting a healthcare provider can be harmful. Option D is incorrect because medroxyprogesterone is typically taken daily, not weekly, for the treatment of endometriosis.

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