Nursing Elites

1. A patient is undergoing a stress test on a treadmill and turns to talk to the nurse. Which of these statements would require the most immediate intervention?

• A. I'm feeling extremely thirsty and will get some water after this.
• B. I can feel my heart racing.
• C. My shoulder and arm are hurting.
• D. My blood pressure reading is 158/80

Correct answer: C

Rationale: The correct answer is 'C: My shoulder and arm are hurting.' Unilateral arm and shoulder pain are classic symptoms of myocardial ischemia, indicating possible heart issues. In this scenario, immediate intervention is required, and the stress test should be halted. Choice A about feeling thirsty does not indicate an acute medical issue. Choice B mentioning heart racing is expected during a stress test. Choice D, a blood pressure reading of 158/80, while slightly elevated, does not present an immediate concern compared to the symptoms of arm and shoulder pain suggesting cardiac distress.

2. Which finding would necessitate an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy?

• A. Weight loss of 2 lb (1 kg)
• B. Positive urine pregnancy test
• C. Hemoglobin level of 10.4 g/dL
• D. Complaints of nausea and anorexia

Correct answer: B

Rationale: A positive urine pregnancy test would require an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy due to the teratogenic effects of ribavirin. Ribavirin needs to be discontinued immediately to prevent harm to the fetus. The other options, weight loss, hemoglobin level, and complaints of nausea and anorexia, are common adverse effects of the prescribed regimen and may necessitate interventions such as patient education or supportive care, but they would not mandate an immediate cessation of therapy as in the case of a positive pregnancy test.

3. A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?

• A. Slow, deep respirations
• B. Stridor
• C. Bradycardia
• D. Air hunger

Correct answer: D

Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (Choice A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (Choice B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (Choice C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.

4. The nurse is caring for a 27-year-old female client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

• A. Apply dressing using sterile technique
• B. Improve the client's nutrition status
• C. Initiate limb compression therapy
• D. Begin proteolytic debridement

Correct answer: B

Rationale: Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. This leads to inadequate oxygen and nutrient supply to the cells in the lower extremities, resulting in cell death or necrosis. Venous stasis ulcers, characterized by shallow brown wounds with irregular margins, typically develop on the lower leg or ankle. The primary goal in managing clients with venous stasis ulcers is to promote healing. Proper nutrition plays a crucial role in wound healing. Nutritional deficiencies are common causes of venous ulcers, and a diet rich in protein, iron, zinc, and vitamins C and A is recommended to enhance wound healing. Applying dressings with sterile technique, initiating limb compression therapy, and beginning proteolytic debridement are important interventions in wound care but may not directly address the underlying issue of poor nutrition that is essential for healing venous stasis ulcers.

5. A systolic blood pressure of 145 mm Hg is classified as:

• A. Normotensive
• B. Prehypertension
• C. Stage I hypertension
• D. Stage II hypertension

Correct answer: C

Rationale: A systolic blood pressure of 145 mm Hg falls within the range of 140-159 mm Hg, which is classified as Stage I hypertension. Normotensive individuals have a systolic blood pressure less than 120 mm Hg, making choice A incorrect. Prehypertension is characterized by a systolic blood pressure ranging from 120-139 mm Hg, excluding choice B. Stage II hypertension is diagnosed when the systolic blood pressure is greater than 160 mm Hg, making choice D incorrect. Therefore, the correct classification for a systolic blood pressure of 145 mm Hg is Stage I hypertension.

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