Nursing Elites

1. Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)

• A. Greater than 1000 cells per deciliter
• B. Less than 500 cells per deciliter
• C. Greater than 2000 cells per deciliter
• D. Less than 200 cells per deciliter

Correct answer: Less than 200 cells per deciliter

Rationale: A T4 cell count of less than 200 cells per deciliter indicates symptomatic AIDS. This severe depletion of T4 cells signifies advanced HIV infection and a significantly compromised immune system. Choices A, B, and C are incorrect because T4 cell counts above 2000, above 1000, or below 500 cells per deciliter, respectively, are not indicative of symptomatic AIDS.

2. What is the next step for a 64-year-old male diagnosed with COPD and CHF who shows a 10 lbs increase in total body weight over the last few days?

• A. Contact the patient’s physician immediately.
• B. Check the intake and output on the patient’s flow sheet.
• C. Encourage the patient to ambulate to reduce lower extremity edema.
• D. Check the patient’s vitals every 2 hours.

Correct answer: Check the intake and output on the patient’s flow sheet.

Rationale: In a patient with COPD and CHF experiencing a sudden increase in total body weight, the priority is to check the intake and output on the patient’s flow sheet to evaluate fluid balance. This assessment helps determine if the weight gain is due to fluid retention, which can exacerbate CHF. Contacting the physician may be necessary based on the intake and output findings. While encouraging ambulation is beneficial for circulation, it may not address the root cause of fluid retention. Checking vitals every 2 hours is important for monitoring stability but may not pinpoint the reason behind the weight gain.

3. Which of the following observations is most important when assessing a client’s breathing?

• A. presence of breathing and pulse rate
• B. breathing pattern and adequacy of breathing
• C. presence of breathing and adequacy of breathing
• D. patient position and adequacy of breathing

Correct answer: presence of breathing and adequacy of breathing

Rationale: The correct answer is the presence of breathing and adequacy of breathing. It is crucial not only to confirm that the client is breathing but also to ensure that the breathing is adequate for proper oxygenation. Choices A, B, and D are incorrect because while pulse rate, breathing pattern, and patient position are relevant aspects to consider, the most critical observations in assessing a client's breathing are the presence and adequacy of breathing.

4. A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?

• A. Administer Loritab to the patient for pain relief.
• B. Place the patient in a right sidelying position for pressure relief.
• C. Start a Central Line.
• D. Provide pain reduction techniques without administering medication.

Correct answer: Provide pain reduction techniques without administering medication.

Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.

5. The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:

• A. use cold applications to the sprain during the first 24–48 hours.
• B. expect disability to decrease within the first 24 hours of injury
• C. expect pain to decrease within 3 hours after injury.
• D. begin progressive passive and active range of motion exercises immediately.

Correct answer: use cold applications to the sprain during the first 24–48 hours.

Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24–48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2–3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2–5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.

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