Nursing Elites

1. A nurse is caring for a client with a newly inserted pacemaker. What is the most important nursing action post-procedure?

• A. Monitor the insertion site for signs of infection.
• B. Educate the client about activity restrictions.
• C. Monitor the client's heart rate and rhythm.
• D. Assess the client's lung sounds for signs of fluid overload.

Correct answer: A

Rationale: Post-procedure, monitoring the insertion site for signs of infection is crucial because it helps in early detection of any potential complications such as infection. While educating the client about activity restrictions, monitoring the client's heart rate and rhythm, and assessing lung sounds for signs of fluid overload are important aspects of care, the immediate priority post-procedure is to prevent infection at the insertion site, which could lead to serious complications.

2. Although stress exposure initiates integrated responses by multiple systems, which system first activates the most important changes?

• A. Pulmonary
• B. Gastrointestinal
• C. Neuroendocrine
• D. Cardiovascular

Correct answer: C

Rationale: The correct answer is C, the Neuroendocrine system. When the body is exposed to stress, the neuroendocrine system plays a crucial role in initiating the body's response. This system, particularly through the hypothalamic-pituitary-adrenal axis, triggers a cascade of physiological responses to stress. Choices A, B, and D are incorrect because while other systems like the cardiovascular and gastrointestinal systems also respond to stress, the neuroendocrine system is primarily responsible for the initial and significant changes in the body's stress response.

3. Which of the following steps occurs first during hemostasis?

• A. Vascular spasm
• B. Platelet plug
• C. Coagulation
• D. Dissolution of the clot

Correct answer: A

Rationale: Vascular spasm is the initial step in hemostasis, where blood vessels constrict to reduce blood flow to the injured area. This constriction helps limit blood loss until further steps like platelet plug formation and coagulation can take place. Platelet plug formation and coagulation occur after the vascular spasm, making them incorrect choices. Dissolution of the clot happens much later in the healing process, after the injury has sufficiently healed.

4. A female patient is prescribed medroxyprogesterone acetate (Provera) for dysfunctional uterine bleeding. What should the nurse include in the patient education?

• A. This medication may cause breakthrough bleeding or spotting.
• B. This medication may cause weight gain.
• C. This medication may increase your risk of developing diabetes.
• D. This medication may increase your risk of breast cancer.

Correct answer: A

Rationale: The correct answer is A. Medroxyprogesterone acetate (Provera) can cause breakthrough bleeding or spotting, which is a common side effect of this medication. Choices B, C, and D are incorrect because weight gain, increased risk of diabetes, and increased risk of breast cancer are not commonly associated side effects of medroxyprogesterone acetate. Therefore, the nurse should focus on educating the patient about the potential for breakthrough bleeding or spotting.

5. Which of the following stores electrolytes and acts as an electrolyte pool?

• A. Brain - Kidneys
• B. Bone - Nails
• C. Bone - Liver
• D. Liver - Pancreas

Correct answer: B

Rationale: Bones store electrolytes and act as a reservoir, maintaining a balance of essential minerals like calcium and phosphate. The correct pair in this context is 'Bone - Nails.' Choices A, C, and D are incorrect because the brain, kidneys, liver, and pancreas perform other functions in the body and are not primarily responsible for storing electrolytes.

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