Nursing Elites

1. A client receiving IV heparin reports abdominal pain and tarry stools. What is the nurse's priority action?

• A. Prepare to administer protamine sulfate.
• B. Continue the heparin infusion and notify the healthcare provider.
• C. Monitor the client's vital signs and assess abdominal pain.
• D. Administer a PRN dose of morphine sulfate.

Correct answer: A

Rationale: The correct answer is to prepare to administer protamine sulfate. Abdominal pain and tarry stools are indicative of gastrointestinal bleeding, a serious side effect of heparin therapy. Protamine sulfate is the antidote for heparin and is used to reverse its effects in cases of bleeding. Continuing the heparin infusion (Choice B) is not appropriate when the client is experiencing signs of bleeding. Monitoring vital signs and assessing abdominal pain (Choice C) is important but not the priority when immediate action is required to address potential bleeding. Administering morphine sulfate (Choice D) is not the priority in this situation; addressing the underlying cause of bleeding takes precedence.

2. During an initial assessment, a healthcare provider notes that a client has elevated blood pressure. Which of the following findings is considered a major risk factor for coronary artery disease?

• A. Elevated HDL cholesterol
• B. Low LDL cholesterol
• C. Elevated blood pressure
• D. Low triglyceride levels

Correct answer: C

Rationale: Elevated blood pressure is a significant risk factor for coronary artery disease because it increases the strain on the arteries, leading to potential damage and a higher risk of developing coronary artery disease. Elevated HDL cholesterol (Choice A) is actually considered beneficial as it helps reduce the risk of heart disease. Low LDL cholesterol (Choice B) is also beneficial as high levels of LDL are associated with an increased risk of coronary artery disease. Low triglyceride levels (Choice D) are not typically considered a major risk factor for coronary artery disease.

3. The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?

• A. Increased TSH
• B. Increased thyroxine (T4)
• C. Decreased TSH
• D. Decreased T3

Correct answer: A

Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.

4. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. What action should the nurse take when finding the radiation implant in the bed?

• A. Call radiation therapy for assistance
• B. Place the implant in a lead container using long-handled forceps
• C. Leave the implant in the bed and notify the provider
• D. Dispose of the implant in the nearest sharps container

Correct answer: B

Rationale: The correct action for the nurse to take when finding the radiation implant in the bed is to use long-handled forceps to place the implant in a lead container. This procedure is crucial in reducing radiation exposure to both the patient and healthcare providers. Calling radiation therapy for assistance (Choice A) may delay the immediate need for safe handling of the implant. Leaving the implant in the bed and notifying the provider (Choice C) is unsafe and can lead to increased radiation exposure. Disposing of the implant in a sharps container (Choice D) is incorrect as the implant should be placed in a lead container, not a sharps container, to contain the radiation.

5. A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?

• A. Multiple firm, round, freely movable masses.
• B. A slight asymmetry of the breasts.
• C. A fixed nodular mass with dimpling of the skin.
• D. Bloody discharge from the nipple.

Correct answer: C

Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.

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