Nursing Elites

1. In which type of cardiomyopathy does septal involvement occur?

• A. Congestive
• B. Dilated
• C. Hypertrophic
• D. Restrictive

Correct answer: C

Rationale: Septal involvement is a characteristic feature of hypertrophic cardiomyopathy, where the septal wall of the heart thickens. This thickening can obstruct blood flow out of the heart, leading to complications such as arrhythmias and heart failure. This differentiates it from other types of cardiomyopathy. In congestive cardiomyopathy (choice A), the heart's chambers become enlarged and weakened, but there is no specific mention of septal involvement. Dilated cardiomyopathy (choice B) involves dilation and impaired contraction of the heart chambers, not specifically septal thickening. Restrictive cardiomyopathy (choice D) is characterized by stiffening of the heart muscle, affecting its ability to fill properly, without direct involvement of the septum.

2. The PN observes a UAP preparing to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take?

• A. Confirm that the UAP completed hand hygiene correctly
• B. Instruct the UAP to wash the hands for one minute
• C. Ask the UAP why the hands were so obviously soiled
• D. Advise the UAP to use the hand rub for 30 seconds

Correct answer: D

Rationale: When hands are visibly soiled, they should be washed with soap and water for at least 20 seconds. However, when using hand rub, it should be applied for at least 30 seconds to be effective. In this scenario, the UAP's hands were visibly soiled, indicating the need for thorough cleaning. Advising the UAP to use the hand rub for 30 seconds is essential to ensure proper hand hygiene and reduce the risk of spreading infection. Choices A, B, and C are incorrect because confirming completion of hand hygiene, instructing to wash for one minute, or asking why the hands were soiled do not address the immediate need for proper hand hygiene in the given situation.

3. A client who had a left hemicolectomy is experiencing a low-grade fever on post-operative day three. What is the nurse's best action?

• A. Encourage deep breathing and the use of the incentive spirometer.
• B. Administer antipyretic medication as prescribed.
• C. Notify the healthcare provider immediately.
• D. Increase the client’s fluid intake.

Correct answer: A

Rationale: A low-grade fever on post-operative day three can be a sign of atelectasis, a common post-operative complication. Encouraging deep breathing and the use of the incentive spirometer can help prevent and treat this condition. Atelectasis is often due to shallow breathing, so option A is the best initial action to promote lung expansion. Administering antipyretic medication (option B) may help reduce the fever but does not directly address the underlying cause. Notifying the healthcare provider immediately (option C) is not necessary at this point unless other concerning symptoms are present. Increasing the client’s fluid intake (option D) is important for overall recovery but is not the priority in this scenario.

4. In obtaining an orthostatic vital sign measurement, what action should the nurse take first?

• A. Count the client's radial pulse
• B. Apply a blood pressure cuff
• C. Instruct the client to lie supine
• D. Assist the client to stand upright

Correct answer: C

Rationale: The correct first action when obtaining an orthostatic vital sign measurement is to instruct the client to lie supine. This allows for establishing a baseline measurement of vital signs before any positional changes. Counting the client's radial pulse (Choice A) is a step that follows after the initial supine position to assess changes in pulse rate. Applying a blood pressure cuff (Choice B) and assisting the client to stand upright (Choice D) are actions that come later in the process after the baseline measurements are obtained in the supine position.

5. A client who is post-operative from a bowel resection is experiencing abdominal distention and pain. The nurse notices the client has not passed gas or had a bowel movement. What should the nurse assess first?

• A. The client's bowel sounds.
• B. The client's fluid intake.
• C. The client's pain level.
• D. The client's surgical incision.

Correct answer: A

Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.

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