Nursing Elites

1. During a screening on a patient with a recent cast on the left lower extremity, which of the following statements should the nurse be most concerned about?

• A. The patient reports, "I didn't keep my extremity elevated as the doctor asked me to."?
• B. The patient reports, "I have been having pain in my left calf."?
• C. The patient reports, "My left leg has really been itching."?
• D. The patient reports, "The arthritis in my wrists is flaring up when I put weight on my crutches."?

Correct answer: B

Rationale: The correct answer is B because pain in the left calf could indicate a potential neurovascular complication related to the casted extremity. It could suggest issues such as compartment syndrome or impaired circulation. Option A is not as concerning since not elevating the extremity may lead to swelling but is not an immediate concern. Option C indicates itching, which is common with casts and not as concerning as potential neurovascular issues. Option D, regarding arthritis in the wrists, is unrelated to the lower extremity issue being screened for.

2. During the admission assessment for a client undergoing breast augmentation, which information should the nurse prioritize reporting to the surgeon before surgery?

• A. The client is concerned about who will care for her two children while she recovers.
• B. The client has a history of postoperative dehiscence after a previous C-section.
• C. The client's statement that her last menstrual period was 8 weeks prior.
• D. The client's concerns over pain control postoperatively.

Correct answer: C

Rationale: The most important information for the nurse to report to the surgeon before surgery is the client's statement that her last menstrual period was 8 weeks prior. This information is crucial as the client may be pregnant, and a pregnancy test will need to be completed before administering any anesthetic agents. Reporting this detail ensures patient safety and prevents potential risks associated with anesthesia. Choices A, B, and D are important aspects of care but do not take precedence over the need to rule out pregnancy before surgery.

3. While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect?

• A. Infection.
• B. Disequilibrium syndrome.
• C. Air embolus.
• D. Infection.

Correct answer: C

Rationale: In this scenario, the client undergoing hemodialysis is experiencing symptoms like restlessness, a headache, and nausea. These symptoms are indicative of an air embolus, a serious complication that can occur during hemodialysis. Air embolus happens when air enters the bloodstream and can lead to symptoms like restlessness, a headache, and nausea. It is crucial for the nurse to suspect and address this complication promptly to prevent further harm to the client. Choices A and D (Infection) are less likely in this case, as the symptoms presented are more suggestive of an air embolus rather than an infection. Choice B (Disequilibrium syndrome) is also less likely as the symptoms described are not typical of this syndrome. Therefore, the correct answer is C: Air embolus.

4. The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?

• A. Asterixis
• B. Hypertension
• C. Kussmaul respirations
• D. Lethargy

Correct answer: A

Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.

5. With a breech presentation, the nurse must be particularly alert for which of the following?

• A. quickening
• B. ophthalmia neonatorum
• C. pica
• D. prolapsed umbilical cord

Correct answer: D

Rationale: With a breech presentation, the nurse must be particularly alert for a prolapsed umbilical cord. Prolapsed umbilical cord is a critical emergency situation where the umbilical cord descends into the vagina before the fetal presenting part, leading to compression between the presenting part and the maternal pelvis. This compression can compromise or completely cut off fetoplacental perfusion, endangering the fetus. Immediate delivery should be attempted to save the fetus. Quickening refers to fetal movements felt by the mother, ophthalmia neonatorum is an eye infection in newborns, and pica is a condition characterized by cravings for non-nutritive substances, none of which are directly related to the risks associated with a breech presentation and prolapsed umbilical cord.

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