Nursing Elites

1. A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?

• A. Hyperthermia related to infectious illness
• B. Impaired transfer ability related to weakness
• C. Ineffective airway clearance related to thick secretions
• D. Impaired gas exchange related to respiratory congestion

Correct answer: D

Rationale: The correct answer is 'Impaired gas exchange related to respiratory congestion.' While all the nursing diagnoses are relevant to the patient's condition, the priority should be given to impaired gas exchange due to the patient's low oxygen saturation level of 88%. This indicates a significant risk of hypoxia for all body tissues unless the gas exchange is improved. Addressing impaired gas exchange is crucial to ensure adequate oxygenation and prevent further complications. Hyperthermia, impaired transfer ability, and ineffective airway clearance are important concerns but addressing gas exchange takes precedence in this scenario.

2. When is cleft palate repair usually performed in children?

• A. A cleft palate cannot be repaired in children.
• B. Repair is usually performed by age 8 weeks.
• C. Repair is usually performed by 2 months of age.
• D. Repair is usually performed between 6 months and 2 years.

Correct answer: D

Rationale: Cleft palate repair timing is individualized based on the severity of the deformity and the child's size. Typically, cleft palate repair is performed between 6 months and 2 years of age. This age range allows for optimal outcomes and is often done before 12 months to promote normal speech development. Early closure of the cleft palate helps to facilitate speech development. Options A, B, and C are incorrect because a cleft palate can be repaired in children, and repair is usually performed between 6 months and 2 years of age, not at 8 weeks or 2 months.

3. A healthcare professional is reviewing a patient's chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?

• A. Borrelia burgdorferi
• B. Streptococcus pyogenes
• C. Bacillus anthracis
• D. Enterococcus faecalis

Correct answer: A

Rationale: Lyme disease, the most common vector-borne disease in the United States, is caused by the bacterium Borrelia burgdorferi. Borrelia burgdorferi is transmitted to humans through the bite of infected black-legged ticks. Streptococcus pyogenes is associated with strep throat and other infections, not Lyme disease. Bacillus anthracis causes anthrax, a separate infectious disease. Enterococcus faecalis is more commonly linked to urinary tract infections and other healthcare-associated infections, not Lyme disease.

4. When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should

• A. assess for the presence of chest pain.
• B. inquire about urinary tract problems.
• C. inspect the skin for rashes or discoloration.
• D. ask the patient about any increase in libido.

Correct answer: B

Rationale: When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.

5. A physician suspects a patient may have pancreatitis. Which of the following tests would be most appropriate to diagnose this condition?

• A. CK and Troponin
• B. BUN and Creatinine
• C. Amylase and Lipase
• D. HDL and LDL Cholesterol Levels

Correct answer: C

Rationale: To diagnose pancreatitis, testing amylase and lipase levels is crucial. Amylase and lipase are enzymes produced by the pancreas that help digest carbohydrates and lipids. In pancreatitis, these enzymes are released in high amounts into the bloodstream due to pancreatic inflammation or damage. Elevated levels of amylase and lipase in blood tests strongly indicate pancreatitis. Choice A, CK and Troponin, are cardiac markers used in diagnosing heart conditions like myocardial infarction, not pancreatitis. Choice B, BUN and Creatinine, are kidney function tests, not specific to pancreatitis. Choice D, HDL and LDL Cholesterol Levels, are lipid profile tests used to assess cardiovascular health, not for diagnosing pancreatitis.

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