Nursing Elites

1. Which of the following signs is NOT indicative of increased intracranial pressure?

• A. Decreased level of consciousness
• B. Projectile vomiting
• C. Sluggish pupil dilation
• D. Increased heart rate

Correct answer: D

Rationale: Increased intracranial pressure can lead to serious complications if not promptly addressed. Common signs of increased intracranial pressure include decreased level of consciousness, sluggish pupil dilation, abnormal respirations, and projectile vomiting. However, an increased heart rate is not a typical sign associated with increased intracranial pressure. It is important for healthcare providers to recognize these signs early to prevent severe consequences such as brain herniation.

2. The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

• A. Oxygen saturation is 88%.
• B. Blood pressure is 145/90 mm Hg.
• C. Respiratory rate is 22 breaths/minute when lying flat.
• D. Pain level is 5 (on a 0 to 10 scale) with a deep breath.

Correct answer: A

Rationale: The correct answer is 'Oxygen saturation is 88%.' Following a thoracentesis, oxygen saturation should improve. A saturation of 88% suggests a potential complication like pneumothorax. While the other assessment findings are important, the priority is to address the low oxygen saturation to prevent further complications. High blood pressure and respiratory rate may also need attention, but the immediate concern is the oxygen saturation level. Pain level, though significant for the patient's comfort, takes lower priority compared to the potential life-threatening issue of hypoxia.

3. A client is brought into the emergency room where the physician suspects that he has cardiac tamponade. Based on this diagnosis, the nurse would expect to see which of the following signs or symptoms in this client?

• A. Fever, fatigue, malaise
• B. Hypotension and distended neck veins
• C. Cough and hemoptysis
• D. Numbness and tingling in the extremities

Correct answer: B

Rationale: Cardiac tamponade occurs when fluid or blood accumulates in the pericardium, preventing the heart from contracting properly. This leads to decreased cardiac output and is considered a medical emergency. Classic signs of cardiac tamponade include hypotension (low blood pressure) and distended neck veins due to the increased pressure around the heart. These signs result from the compromised ability of the heart to pump effectively. Choices A, C, and D are not typically associated with cardiac tamponade. Fever, fatigue, and malaise are non-specific symptoms that can be seen in various conditions. Cough and hemoptysis are more commonly associated with respiratory conditions, while numbness and tingling in the extremities are neurological symptoms not typically seen in cardiac tamponade.

4. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?

• A. Notify the healthcare provider
• B. Document the response to exercise
• C. Administer the PRN supplemental O2
• D. Encourage the patient to pace activity

Correct answer: C

Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. Administering PRN supplemental oxygen is the priority action to correct the hypoxemia and ensure adequate oxygenation during activity. Notifying the healthcare provider can be done after stabilizing the patient's oxygen levels. Documenting the response to exercise is important but secondary to addressing the immediate hypoxemia. Encouraging the patient to pace activity is not sufficient to address the acute drop in SpO2 and provide the necessary oxygen support.

5. The parents of an infant who underwent surgical repair of bladder exstrophy ask if the infant will be able to control their bladder as they get older. How should the nurse respond?

• A. Your child will need catheterization until bladder control is gained.
• B. Your child will be able to control their bladder like other children.
• C. You should potty train your child at the same time you normally would.
• D. Your child will not have a sphincter mechanism for the first 3 to 5 years, so urine will drain freely.

Correct answer: D

Rationale: Bladder exstrophy is a congenital defect where the infant is born with the bladder located on the outside of the body. Surgical repair typically occurs within the first 1 to 2 days of life. In the following 3 to 5 years post-surgery, urine will drain freely from the urethra due to the absence of a sphincter mechanism. This period allows the bladder to develop capacity as the child grows. Subsequent surgical interventions will be required to establish a functioning sphincter mechanism. Therefore, the correct response is that the child will not have a sphincter mechanism for the first 3 to 5 years, leading to urine draining freely. Options A, B, and C are incorrect as they do not align with the physiological process and management of bladder exstrophy.

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