Nursing Elites

1. While assessing a critically ill client in the emergency department, the nurse notes on the cardiac monitor an R-on-T premature ventricular beat that develops into ventricular tachycardia (VT). Immediately, the client became unresponsive. The nurse knows that based on pathophysiologic principles, the most likely cause of the unresponsiveness is:

• A. metabolic acidosis that occurs spontaneously following any dysrhythmias.
• B. interruption of the blood/oxygen supply to the brain.
• C. massive cerebrovascular accident (CVA) resulting from increased perfusion.
• D. a blood clot coming from the heart and occluding the carotid arteries.

Correct answer: B

Rationale: The correct answer is B. Ventricular tachycardia (VT) can disrupt the normal heart function, leading to a decreased cardiac output. This decreased output can interrupt the blood supply to the brain, causing the client to become unresponsive. Metabolic acidosis (Choice A) is not the most likely cause of unresponsiveness in this scenario. A massive cerebrovascular accident (CVA) (Choice C) would not result from increased perfusion. A blood clot occluding the carotid arteries (Choice D) may lead to a stroke but is not the most likely cause of sudden unresponsiveness in this situation.

2. Canola oil produced from genetically modified canola plants altered to be herbicide-resistant is an example of a:

• A. pesticide-free food.
• B. saturated fat food.
• C. genetically modified food.
• D. product that is pure.

Correct answer: C

Rationale: The correct answer is 'genetically modified food.' Canola oil derived from genetically modified canola plants falls into this category because the plant's genome has been altered to exhibit herbicide resistance. This genetic modification makes it a genetically modified food. Choice A, 'pesticide-free food,' is incorrect as the genetic modification is to resist herbicides, not pesticides. Choice B, 'saturated fat food,' is incorrect as it does not accurately describe the genetic modification of the canola plants. Choice D, 'product that is pure,' is too vague and does not address the genetic modification aspect of the canola plants.

3. During surgery, the anesthesia personnel notice the client is having a steady rise in end-tidal carbon dioxide level. At this time, the nurse anesthetist begins to assess the client for malignant hyperthermia. The initial (priority) assessment for this disorder may include:

• A. measuring serum potassium levels.
• B. monitoring for muscle rigidity.
• C. evaluating renal function.
• D. checking arterial blood gases.

Correct answer: B

Rationale: The correct answer is B: monitoring for muscle rigidity. Muscle rigidity is a hallmark sign of malignant hyperthermia, a life-threatening condition triggered by certain anesthetics. Monitoring for this sign is critical in the early identification of the condition. Choices A, C, and D are not the initial priority assessments for malignant hyperthermia. Measuring serum potassium levels, evaluating renal function, and checking arterial blood gases are not specific initial assessments for malignant hyperthermia and would not aid in its early identification.

4. Which of the following is a sign of hypoglycemia?

• A. Rapid, deep breathing
• B. Increased urination
• C. Weakness and confusion
• D. High blood pressure

Correct answer: C

Rationale: The correct answer is C: Weakness and confusion. Hypoglycemia is characterized by low blood sugar levels, leading to inadequate glucose supply to the brain, resulting in symptoms like weakness and confusion. Choices A, B, and D are incorrect. Rapid, deep breathing is not typically a sign of hypoglycemia but can be seen in other conditions like respiratory issues. Increased urination is more commonly associated with conditions like diabetes mellitus, while high blood pressure is not a typical sign of hypoglycemia.

5. Which information would indicate more teaching is needed regarding hypersensitivity reactions? Type _______ hypersensitivity reactions involve an antibody response.

• A. I
• B. II
• C. III
• D. IV

Correct answer: D

Rationale: The correct answer is D: Type IV hypersensitivity reactions involve cell-mediated immunity, not an antibody response. This question tests knowledge of hypersensitivity reactions and their classification. Type I hypersensitivity reactions involve IgE antibodies, Type II involves IgG or IgM antibodies, and Type III involves immune complex deposition. Type IV hypersensitivity reactions are delayed and involve T cells, not antibodies. Therefore, if a person believes that Type IV hypersensitivity reactions involve an antibody response, more teaching is required.

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