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. A client diagnosed with heart failure displays bilateral pitting edema of the lower extremities. Which of the following terms is used to describe this finding?

• A. Contraindication
• B. Sign
• C. Symptom
• D. Subjective data

Correct answer: B

Rationale: The correct answer is 'B. Sign.' In this scenario, bilateral pitting edema is an objective finding that can be observed by others, making it a sign of heart failure. Choice A, 'Contraindication,' refers to a factor that makes a particular treatment or procedure potentially harmful. Choice C, 'Symptom,' is a subjective indication of a condition experienced by the client. Choice D, 'Subjective data,' is information that is reported by the client but cannot be directly observed or measured.

3. Where are most body fluids located?

• A. Intravascular space.
• B. Intracellular space.
• C. Extracellular space.
• D. Transcellular space.

Correct answer: B

Rationale: Most body fluids are located within cells in the intracellular space. While the extracellular space also contains body fluids, the majority is found within the cells. Intravascular space refers to fluids within blood vessels, and transcellular space includes fluids in compartments like cerebrospinal, pleural, and peritoneal cavities.

4. As you are walking in the park, a huge black Labrador runs up to you and places his paws on your shoulders. Immediately your heart starts racing, you feel palpitations, anxiety, and your hands become a little shaky. The nurse knows that this response is primarily caused by:

• A. cerebral cortex.
• B. somatic nervous system.
• C. limbic system.
• D. autonomic nervous system.

Correct answer: D

Rationale: The autonomic nervous system controls involuntary bodily functions like heart rate, respiration, and sweating. In the given scenario, the 'fight or flight' response is activated, leading to increased heart rate, palpitations, anxiety, and shaky hands. The cerebral cortex is involved in conscious thought processes and decision-making, not the immediate physiological response observed here. The somatic nervous system regulates voluntary movements, while the limbic system is responsible for emotions and memory, but the autonomic nervous system is primarily responsible for the physiological responses seen in this situation.

5. A client with a history of tuberculosis (TB) is experiencing a recurrence of symptoms. Which diagnostic test should the nurse anticipate being ordered?

• A. Sputum culture
• B. Bronchoscopy
• C. Chest x-ray
• D. CT scan of the chest

Correct answer: C

Rationale: A chest x-ray is the most appropriate diagnostic test for a client with a history of tuberculosis experiencing a recurrence of symptoms. A chest x-ray is commonly used to visualize the lungs and check for signs of active tuberculosis, such as abnormal shadows or nodules. While a sputum culture (Choice A) can confirm the presence of TB bacteria, it may not be the initial test ordered for a recurrence. Bronchoscopy (Choice B) and CT scan of the chest (Choice D) are more invasive and usually reserved for cases where the chest x-ray is inconclusive or to further assess complications, rather than as the initial diagnostic test for a recurrence of tuberculosis.

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