Nursing Elites

1. A patient in the emergency department reports taking sildenafil (Viagra) and nitroglycerin 1 hr before sexual activity. Which finding should the nurse immediately report to the physician?

• A. WBC of 3200 cells/mm³
• B. RR of 26 breaths/min
• C. Temp of 38°C
• D. BP of 70/50

Correct answer: D

Rationale: The correct answer is D: BP of 70/50. When sildenafil (Viagra) is taken with nitroglycerin, it can cause severe hypotension that is unresponsive to treatment. The combination of these medications can lead to a dangerous drop in blood pressure. It is crucial to immediately report hypotension in this scenario as it poses a significant risk to the patient's life. It is recommended to allow at least 24 hours to elapse between the last dose of sildenafil and nitroglycerin to prevent such adverse effects. The other vital signs and lab values may be abnormal but do not have the immediate life-threatening implications that severe hypotension does in this context.

2. During an assessment, which manifestation should a healthcare provider expect in an infant with pyloric stenosis?

• A. Bile-stained vomitus
• B. Distended abdomen
• C. Olive-shaped mass in the upper abdomen
• D. Painless, swollen joints

Correct answer: C

Rationale: Pyloric stenosis in infants typically presents with an olive-shaped mass in the upper abdomen due to hypertrophy of the pyloric muscle. This mass can often be palpated during an assessment and is a key characteristic of this condition. Bile-stained vomitus may be seen in conditions such as intestinal obstruction; a distended abdomen can be a nonspecific sign of various conditions, and painless, swollen joints are not typically associated with pyloric stenosis.

3. A school nurse is assessing a school-age child�s blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first?

• A. Clear the immediate area around the child of hazardous objects
• B. loosen the child�s restrictive clothing
• C. assist the child to a side-lying position on the floor
• D. apply an oxygen mask to the child

Correct answer: C

Rationale: The greatest risk to this child is aspiration, occlusion of the airway, and bodily injury from falling out of the chair. The nurse should ease the child down to the floor in a side-lying position immediately.

4. In which frame of reference do activities involve responses to movement, balance, weight bearing, and tactile activities?

• A. Motor control/motor learning
• B. Ayres' sensory integration
• C. Neurodevelopmental treatment
• D. Developmental

Correct answer: B

Rationale: Ayres' sensory integration focuses on activities that target responses to movement, balance, weight bearing, and tactile stimuli to improve sensory processing and integration. This approach aims to address sensory challenges through structured activities to enhance overall function and participation. Motor control/motor learning (Choice A) deals with the control and coordination of voluntary movements. Neurodevelopmental treatment (Choice C) focuses on facilitating normal movement patterns and postural control. Developmental (Choice D) refers to the natural sequence of growth and development in children.

5. The patient taking warfarin for prevention of deep vein thrombosis has an INR of 1.2. Which action by the nurse is most appropriate?

• A. Administer IV push protamine sulfate
• B. Continue with the current prescription.
• C. Prepare to administer Vitamin K
• D. Call healthcare provider to increase the dose

Correct answer: D

Rationale: An INR level of 1.2 is below the therapeutic range (2-3) for warfarin therapy. Therefore, the nurse should contact the healthcare provider to discuss the need for an increased dose to achieve the desired therapeutic range and prevent deep vein thrombosis effectively. Administering IV push protamine sulfate is used to reverse the effects of heparin, not warfarin. Continuing with the current prescription without addressing the subtherapeutic INR level may not effectively prevent deep vein thrombosis. Administering Vitamin K is indicated for warfarin overdose leading to excessive anticoagulation, not for a subtherapeutic INR level that is below the target range.

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