Nursing Elites

1. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

• A. Distended, board-like abdomen
• B. WBC count of 15,000/mm3
• C. Rebound tenderness over McBurney's point
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: A distended, board-like abdomen should be reported to the provider immediately because it indicates peritonitis, a serious complication of appendicitis resulting from a ruptured appendix. Option B, an elevated WBC count, may indicate infection but is not as urgent as a board-like abdomen. Option C, rebound tenderness over McBurney's point, is a classic sign of appendicitis but does not indicate immediate life-threatening complications. Option D, a slightly elevated temperature, is not as concerning as a distended, board-like abdomen.

2. A patient with ventricular tachycardia and a pulse needs electrical intervention. What is the appropriate action?

• A. Defibrillation
• B. Synchronized cardioversion
• C. Pacing
• D. Medication administration

Correct answer: B

Rationale: For a patient with ventricular tachycardia and a pulse, the appropriate action is synchronized cardioversion. Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing is typically used for bradycardias. Medication administration may be considered in stable ventricular tachycardia cases but electrical intervention is preferred for immediate correction in this scenario.

3. What dietary recommendations should a patient with GERD follow?

• A. Avoid mint and spicy foods
• B. Consume liquids between meals
• C. Eat three large meals per day
• D. Drink milk as a snack

Correct answer: A

Rationale: Patients with GERD should follow dietary recommendations to manage their symptoms effectively. Choice A, 'Avoid mint and spicy foods,' is the correct answer. Mint and spicy foods can trigger acid reflux and worsen GERD symptoms. Choice B, 'Consume liquids between meals,' is not the best recommendation as consuming liquids during meals can worsen GERD symptoms by increasing stomach pressure. Choice C, 'Eat three large meals per day,' is incorrect as large meals can exacerbate GERD symptoms; instead, smaller, more frequent meals are recommended. Choice D, 'Drink milk as a snack,' is not ideal as full-fat dairy products like milk can trigger acid reflux in some individuals. Therefore, the best recommendation for a patient with GERD is to avoid mint and spicy foods.

4. What should be monitored in a patient receiving insulin who is at risk for hypoglycemia?

• A. Monitor blood glucose levels
• B. Monitor for respiratory distress
• C. Monitor for hypertension
• D. Monitor for hyperkalemia

Correct answer: A

Rationale: Corrected Question: In a patient receiving insulin who is at risk for hypoglycemia, monitoring blood glucose levels is crucial. This helps in preventing and identifying hypoglycemia promptly. Choice B, monitoring for respiratory distress, is not directly related to hypoglycemia caused by insulin. Choice C, monitoring for hypertension, is not typically associated with hypoglycemia. Choice D, monitoring for hyperkalemia, is not a common concern in patients receiving insulin who are at risk for hypoglycemia.

5. What is the initial action for treating chest pain in acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Administer aspirin
• C. Check cardiac enzymes
• D. Obtain IV access

Correct answer: A

Rationale: The correct initial action for treating chest pain in acute coronary syndrome is to administer sublingual nitroglycerin. Nitroglycerin helps dilate blood vessels, reducing the workload on the heart and improving blood flow to the heart muscle. Administering aspirin can also be beneficial, but the priority is to address chest pain promptly. Checking cardiac enzymes and obtaining IV access are important steps but are not the initial actions needed to alleviate chest pain in acute coronary syndrome.

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