Nursing Elites

1. While palpating the gallbladder of a mildly obese client, what finding does the nurse expect if the gallbladder is inflamed?

• A. Severe tenderness and guarding
• B. Slight discomfort upon palpation
• C. A sensation of fullness
• D. No symptoms unless the gallbladder is extremely inflamed

Correct answer: A

Rationale: Correct. If the gallbladder is inflamed, the nurse would expect to find severe tenderness and guarding, which are typical signs of acute cholecystitis. This indicates an inflammatory process in the gallbladder. Choices B, C, and D are incorrect because slight discomfort, a sensation of fullness, or no symptoms unless extremely inflamed are not typical findings associated with gallbladder inflammation.

2. When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency?

• A. Reports of leg cramping at rest
• B. Family history of heart disease
• C. Current use of beta-blockers
• D. History of intermittent claudication

Correct answer: D

Rationale: Corrected Rationale: Intermittent claudication, or pain in the legs while walking that is relieved by rest, is a classic symptom of peripheral arterial insufficiency. Other factors such as a family history or medication use may contribute to cardiovascular health, but claudication is the most specific indicator. Leg cramping at rest is more indicative of conditions like peripheral neuropathy or deep vein thrombosis. Family history of heart disease and current use of beta-blockers are relevant to overall cardiovascular health, but they are not as directly related to chronic peripheral arterial insufficiency as intermittent claudication.

3. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

4. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

• A. Disconnect the client from the ventilator and use a manual resuscitation bag
• B. Perform a quick assessment of the client's condition
• C. Call the respiratory therapist for help
• D. Press the alarm reset button on the ventilator

Correct answer: B

Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.

5. A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?

• A. Auscultate breath sounds.
• B. Measure vital signs.
• C. Palpate the abdomen.
• D. Observe the skin for bruising.

Correct answer: C

Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.

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