Nursing Elites

1. A patient's nurse taking a history notes complaints of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia and hypertension. Which of the following may be occurring?

• A. The patient may be developing CHF
• B. The patient may be having a MI
• C. The patient may be developing COPD
• D. The patient may be having an onset of PVD

Correct answer: B

Rationale: In this scenario, the patient's symptoms of shortness of breath (SOB) and weakness in the lower extremities, along with a history of hyperlipidemia and hypertension, are suggestive of a myocardial infarction (MI). It is important to note that MI can present with a variety of symptoms, including those affecting the respiratory system and muscle weakness. Choices A, C, and D are incorrect because the patient's symptoms are more indicative of a myocardial infarction rather than congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or peripheral vascular disease (PVD).

2. When auscultating breath sounds, the nurse auscultates over the following locations:

• A. Trachea and lateral areas of thoracic cage
• B. Anterior and posterior aspects of all lung fields
• C. The mid section as well as the lateral section of the lungs
• D. The mid-clavicular to mid-axillary lines comparing side to side

Correct answer: B

Rationale: The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs. Choices A, C, and D are incorrect. Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields. Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section). Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.

3. A nurse assesses an 83-year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage, and the patient has limited mobility in her home. Which of the following is the best course of action?

• A. Encourage warm water soaks to the right foot.
• B. Notify the case manager of the purulent drainage.
• C. Determine the patient's pulse in the right ankle.
• D. Recommend increased activity to reduce the purulent drainage.

Correct answer: A

Rationale: The correct course of action is to encourage warm water soaks to the right foot. This can help promote wound healing and alleviate discomfort. Before recommending increased activity or notifying additional team members, it is crucial to assess arterial blood flow by determining the patient's pulse in the right ankle. Poor arterial blood flow could worsen the condition, making increased activity inappropriate. While notifying the case manager of purulent drainage is important, addressing the wound care directly should be the primary focus at this stage.

4. A 62-year-old female is being seen on a home visit by a nurse. The patient reports she has been taking Premarin for years. Which of the following would indicate an overdose?

• A. Lower extremity edema
• B. Sensory changes in the upper extremities
• C. Increased occurrence of fractures
• D. Decreased peripheral blood flow

Correct answer: A

Rationale: Lower extremity edema can indicate an overdose of Premarin. Premarin, an estrogen hormone replacement therapy, can cause fluid retention leading to edema in the lower extremities. Sensory changes in the upper extremities, increased occurrence of fractures, and decreased peripheral blood flow are not typically associated with an overdose of Premarin.

5. For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?

• A. Headache
• B. Pruritus
• C. Vomiting
• D. Hypertension

Correct answer: A

Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat. To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.

Similar Questions