Nursing Elites

1. While walking to the mailbox, an older adult male experiences sudden chest tightness and drives himself to the emergency department. When the client gets up to the desk of the triage nurse, he says his heart is pounding out of his chest as he clutches his chest and falls to the floor. Which intervention should the nurse implement first?

• A. Prepare for cardiac defibrillation.
• B. Apply cardiac monitor leads.
• C. Obtain troponin serum levels.
• D. Palpate the client’s artery.

Correct answer: D

Rationale: Palpating the client's artery is the priority intervention in this scenario because it helps determine if there is a pulse, which is crucial information in emergency situations like this. If the client is pulseless, immediate initiation of CPR is necessary. Applying cardiac monitor leads or obtaining troponin serum levels can wait until the presence of a pulse is confirmed. Cardiac defibrillation is not indicated without first assessing the client's pulse and cardiac rhythm.

2. A woman with chronic osteoarthritis is complaining of knee pain. Which pathophysiological process is contributing to her pain?

• A. Inflammation of the synovial membrane.
• B. Degeneration of the cartilage in the joint.
• C. Joint inflammation occurs when chondrocyte injury destroys joint cartilage, producing osteophytes.
• D. Formation of uric acid crystals in the joint space.

Correct answer: C

Rationale: The correct answer is C. In osteoarthritis, the breakdown of cartilage in the joints leads to chondrocyte injury, which results in the destruction of joint cartilage and the production of osteophytes. This process causes joint inflammation and pain. Choice A is incorrect because osteoarthritis primarily involves the articular cartilage rather than the synovial membrane. Choice B is incorrect as it describes the degeneration of cartilage but does not explain the specific pathophysiological process contributing to pain in osteoarthritis. Choice D is incorrect as the formation of uric acid crystals is characteristic of gout, not osteoarthritis.

3. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?

• A. Palpate for abdominal distention
• B. Send fluid to the lab for analysis
• C. Continue to monitor the fluid output
• D. Clamp the drainage tube for 5 minutes

Correct answer: C

Rationale: Continuing to monitor the fluid output is the appropriate action in this situation. Monitoring the fluid output helps the nurse assess the client's ongoing response to the procedure and detect any sudden changes, such as increased or decreased drainage rate, which could indicate complications. Palpating for abdominal distention, sending fluid to the lab for analysis, or clamping the drainage tube are not necessary actions at this point, as the priority is to monitor the client's condition post-procedure.

4. A client with a history of seizures is prescribed phenytoin. Which side effect should the nurse instruct the client to report?

• A. Drowsiness
• B. Gingival hyperplasia
• C. Weight gain
• D. Blurred vision

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, which is an overgrowth of gum tissue. This side effect is important to report to the healthcare provider because it can lead to oral health problems. Choice A, drowsiness, is a common side effect of many antiepileptic drugs but is not specific to phenytoin. Choice C, weight gain, is not a typical side effect of phenytoin. Choice D, blurred vision, is not a common side effect of phenytoin; it is more commonly associated with other medications.

5. What is the hallmark sign of intussusception?

• A. Mucus-like stools
• B. Currant jelly-like stools
• C. Tarry, black stools
• D. Green, soft stools

Correct answer: B

Rationale: The hallmark sign of intussusception is currant jelly-like stools, which result from the mixture of blood and mucus in the stool due to the sloughing of intestinal mucosa. Mucus-like stools (Choice A) are not typically associated with intussusception. Tarry, black stools (Choice C) are characteristic of gastrointestinal bleeding higher up in the gastrointestinal tract, such as from a peptic ulcer. Green, soft stools (Choice D) are more indicative of rapid transit through the intestines, possibly due to dietary factors or infections such as gastroenteritis.

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