Nursing Elites

1. A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

• A. Assist with active range of motion (ROM).
• B. Observe for agitation and paranoia.
• C. Give muscle relaxants as needed to reduce spasms.
• D. Use simple words and phrases to explain procedures.

Correct answer: A

Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.

2. The healthcare professional calculates the IV flow rate for a patient receiving an antibiotic. The patient is to receive 100mL of the antibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. How many drops per minute should the healthcare professional set the IV to deliver?

• A. 11
• B. 19
• C. 26
• D. 33

Correct answer: D

Rationale: To determine the drops per minute for the IV flow rate, you can use the formula: Drops Per Minute = (Milliliters to be infused x Drop Factor) / Time in Minutes. Substituting the given values, you get 100 mL x 10 drops/mL / 30 minutes = 33 drops per minute. Therefore, the correct answer is 33, as the healthcare professional should set the IV to deliver 33 drops per minute to infuse the antibiotic correctly. Choices A, B, and C are incorrect as they do not match the calculated drops per minute based on the provided values.

3. The nurse is caring for an infant with cryptorchidism. The nurse anticipates that the most likely diagnostic study to be prescribed would be the one that assesses which item?

• A. Babinski reflex
• B. DNA synthesis
• C. Urinary function
• D. Chromosomal analysis

Correct answer: C

Rationale: Cryptorchidism, also known as undescended testes, may be caused by hormonal deficiency, intrinsic testicular abnormality, or a structural problem. Diagnostic studies for cryptorchidism typically involve assessing urinary function because the kidneys and testes originate from the same embryonic tissue. The Babinski reflex is a test for neurological function and is not relevant to evaluating cryptorchidism. DNA synthesis and chromosomal analysis are not commonly used diagnostic tests for cryptorchidism, as they are unrelated to the disorder's etiology or presentation.

4. Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?

• A. Increased serum albumin level
• B. Decreased indirect bilirubin level
• C. Improved alertness and orientation
• D. Fewer episodes of bleeding varices

Correct answer: D

Rationale: The correct answer is 'Fewer episodes of bleeding varices.' A transjugular intrahepatic portosystemic shunt (TIPS) is used to reduce pressure in the portal venous system, thus decreasing the risk of bleeding from esophageal varices. This outcome would indicate the effectiveness of the TIPS procedure. The other choices are incorrect because: Increased serum albumin level and decreased indirect bilirubin level are not direct indicators of TIPS effectiveness. Improved alertness and orientation could be influenced by various factors and may not directly correlate with the effectiveness of the TIPS procedure. Additionally, TIPS can actually increase the risk of hepatic encephalopathy, which contradicts the choice of improved alertness and orientation.

5. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?

• A. Document the presence of continuous bubbling.
• B. Notify the surgeon of a possible pneumothorax.
• C. Take no further action with the collection device.
• D. Adjust the dial on the wall regulator to decrease suction.

Correct answer: C

Rationale: Continuous bubbling in the suction-control chamber of the chest tube collection device is an expected finding and indicates that the suction control chamber is connected to suction. It does not necessarily indicate a large air leak, which would be detected in the water-seal chamber. There is no evidence to suggest a pneumothorax based solely on continuous bubbling in the suction-control chamber. Adjusting the suction level by changing the wall regulator setting is not indicated in this situation, as the amount of suction applied is primarily regulated by the water level in the water-seal chamber and not by the vacuum source. Therefore, the most appropriate action in this scenario is for the nurse to take no further action with the collection device.

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