Nursing Elites

1. A client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the healthcare provider ordering?

• A. Paracentesis
• B. Chest tube insertion
• C. Lumbar puncture
• D. Biopsy of the pancreas

Correct answer: B

Rationale: The correct answer is B: Chest tube insertion. A chest tube may be needed if a pancreatic pseudocyst ruptures into the pleural space, causing a pleural effusion. Paracentesis (choice A) involves the removal of fluid from the abdominal cavity, not typically indicated for a pancreatic pseudocyst. Lumbar puncture (choice C) is a procedure to collect cerebrospinal fluid from the spinal canal, not relevant to a pancreatic pseudocyst. Biopsy of the pancreas (choice D) is a diagnostic procedure to obtain tissue samples for examination and is not typically done in the context of a ruptured pseudocyst.

2. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

• A. Building rapport with the child
• B. Taking the child’s temperature
• C. A, D
• D. Obtaining an interpreter if necessary

Correct answer: C

Rationale: Building rapport with the child is essential to establish trust and cooperation during the assessment. Admiring the child may not be appropriate in a professional setting and might not contribute significantly to the assessment. Taking the child's temperature is a routine part of the assessment but may not be the most critical action in this scenario. Obtaining an interpreter is crucial to ensure effective communication between the healthcare team and the child and their mother, especially considering potential language barriers.

3. The nurse understands that which are characteristics of anthrax? Select all that apply.

• A. Cutaneous lesions become a black eschar, Flu-like symptoms are a sign of pulmonary anthrax
• B. Cutaneous lesions become a black eschar
• C. Gastrointestinal anthrax causes blood anthrax
• D. Flu-like symptoms are a sign of pulmonary anthrax

Correct answer: A

Rationale: The correct characteristics of anthrax are that cutaneous lesions become a black eschar, and flu-like symptoms are typical of pulmonary anthrax. Choice B is incorrect as it only covers the cutaneous anthrax characteristic and does not include the flu-like symptoms of pulmonary anthrax. Choice C is incorrect as gastrointestinal anthrax does not cause 'blood anthrax,' and Choice D is incorrect as flu-like symptoms are not associated with gastrointestinal anthrax.

4. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

• A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
• B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
• C. 56-year-old fourth hospital day after coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization
• D. 86-year-old; 48 hours postoperative repair of fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter

Correct answer: A

Rationale: The correct answer is A. This client situation presents with concerning clinical signs such as no urine output post kidney transplant, elevated temperature, tachycardia, hypotension, and restlessness, suggestive of acute renal failure and sepsis. These signs necessitate immediate intervention by the rapid response team (RRT) to address the potentially life-threatening conditions. Choice B is incorrect as the client is stable after chest tube removal and primarily anxious about going home. Choice C is incorrect as the client's symptoms are related to postoperative recovery and boredom, not indicating an urgent need for RRT consultation. Choice D is incorrect as the client post hip repair is stable, alert, and interacting normally, without signs of acute deterioration requiring RRT involvement.

5. Why may patients with hiatal hernia develop anemia?

• A. Iron absorption is reduced
• B. Gastritis may cause bleeding
• C. Iron stores turn over more quickly
• D. Patients have an aversion to foods that are good sources of iron

Correct answer: B

Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can occur due to the reflux of stomach acid into the esophagus. This gastritis can lead to gastrointestinal bleeding, resulting in anemia. Choice A is incorrect because iron absorption is not necessarily reduced in hiatal hernia. Choice C is incorrect as iron stores turnover rate is not directly related to the development of anemia in this context. Choice D is incorrect as an aversion to iron-rich foods is not a common reason for anemia in patients with hiatal hernia.

Similar Questions