Nursing Elites

1. What should the nurse do before an echocardiogram for a client who has had a myocardial infarction?

• A. Ensuring no food or drink for 4 hours before the procedure
• B. Obtaining informed consent from the client
• C. Assessing for any history of iodine or shellfish allergies
• D. Informing the client about the painless nature and duration of the procedure

Correct answer: D

Rationale: The correct answer is to inform the client that the echocardiogram is a painless procedure that usually takes 30 to 60 minutes to complete. Echocardiography is a noninvasive, risk-free, and pain-free test that uses ultrasound to evaluate the heart's structure and motion. There is no need for special preparation before the procedure. Choices A, B, and C are incorrect because imposing nothing-by-mouth status, obtaining informed consent, and assessing for allergies to iodine or shellfish are not necessary steps before an echocardiogram.

2. Which of the following is a characteristic symptom of multiple sclerosis (MS)?

• A. Muscle atrophy.
• B. Severe pain.
• C. Vision problems.
• D. Hearing loss.

Correct answer: C

Rationale: Vision problems are a characteristic symptom of multiple sclerosis (MS) due to demyelination of the optic nerve. This can lead to issues such as optic neuritis, blurred vision, double vision, or even total vision loss. Muscle atrophy (Choice A) is not a primary symptom of MS but can occur as a secondary effect of decreased mobility. Severe pain (Choice B) is not a typical symptom of MS, though some individuals may experience pain related to muscle spasms or other factors. Hearing loss (Choice D) is not commonly associated with MS unless there is an unrelated concurrent condition affecting the auditory system.

3. The client with chronic renal failure is being taught about dietary restrictions by the nurse. Which of the following food items should the client avoid?

• A. Apples
• B. Bananas
• C. Chicken
• D. Rice

Correct answer: B

Rationale: The correct answer is B: Bananas. Bananas are high in potassium, which should be limited in clients with chronic renal failure to prevent hyperkalemia. Apples (choice A), chicken (choice C), and rice (choice D) are not typically restricted in clients with chronic renal failure. Apples and rice are lower in potassium, while chicken is a good source of lean protein, which is usually encouraged in these clients to meet their protein needs without excess potassium intake.

4. A client who experienced partial-thickness burns involving over 50% body surface area (BSA) 2 weeks ago has several open wounds and develops watery diarrhea. The client's blood pressure is 82/40 mmHg, and temperature is 96°F (36.6°C). Which action is most important for the nurse to take?

• A. Increase the room temperature.
• B. Assess the oxygen saturation.
• C. Continue to monitor vital signs.
• D. Notify the rapid response team.

Correct answer: D

Rationale: In this scenario, the client is presenting with signs of sepsis, such as hypotension, hypothermia, and a recent history of partial-thickness burns with open wounds. The development of watery diarrhea further raises suspicion for sepsis. With a blood pressure of 82/40 mmHg and a low temperature of 96°F (36.6°C), the nurse should recognize the potential for septic shock. Notifying the rapid response team is crucial in this situation as the client requires immediate intervention and management to prevent deterioration and address the underlying septic process. Increasing the room temperature (Choice A) is not the priority as the low body temperature is likely due to systemic vasodilation and not environmental factors. While assessing oxygen saturation (Choice B) is important, the client's hypotension and hypothermia take precedence. Continuing to monitor vital signs (Choice C) alone is insufficient given the critical condition of the client and the need for prompt action to address the sepsis and potential septic shock.

5. A client with elevated levels of antidiuretic hormone (ADH) triggers the release of this hormone due to which disorder?

• A. Pneumonia
• B. Dehydration
• C. Renal failure
• D. Edema

Correct answer: B

Rationale: Antidiuretic hormone (ADH) increases tubular permeability to water, causing more water absorption into the capillaries. ADH is released in response to a rising extracellular fluid osmolarity, such as in dehydration. Pneumonia, renal failure, and edema do not typically lead to the release of ADH. Pneumonia is an inflammatory lung condition, renal failure affects kidney function, and edema is the accumulation of excess fluid in the tissues, none of which directly stimulate the release of ADH.

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