Nursing Elites

1. The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies?

• A. Observe for distended neck veins.
• B. Auscultate for crackles in the lungs.
• C. Palpate for heaves or thrills over the heart.
• D. Review hemoglobin and hematocrit values.

Correct answer: A

Rationale: To evaluate the effectiveness of therapies for cor pulmonale and right-sided heart failure, observing for distended neck veins would be the most appropriate assessment. Cor pulmonale is characterized by right ventricular failure due to pulmonary hypertension, leading to clinical manifestations such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness. These signs indicate increased central venous pressure and right heart strain, which can be assessed by observing for distended neck veins. Auscultating for crackles in the lungs is more indicative of left-sided heart failure rather than right-sided heart failure. Heaves or thrills over the heart are not typically associated with cor pulmonale. Reviewing hemoglobin and hematocrit values may show elevations due to chronic hypoxemia and polycythemia in cor pulmonale, but these values alone do not directly evaluate the immediate effectiveness of the prescribed therapies on the patient's condition.

2. The clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment?

• A. Reports of frothy stools and diarrhea
• B. Reports of foul-smelling ribbon stools
• C. Reports of profuse, watery diarrhea and vomiting
• D. Reports of diffuse abdominal pain unrelated to meals or activity

Correct answer: A

Rationale: Lactose intolerance commonly presents with frothy stools and diarrhea due to the inability to digest lactose. Other symptoms include abdominal distension, crampy abdominal pain, and excessive flatus. Foul-smelling ribbon stools are indicative of Hirschsprung's disease, not lactose intolerance. Profuse, watery diarrhea and vomiting are more characteristic of celiac disease. Diffuse abdominal pain unrelated to meals or activity is a typical symptom of irritable bowel syndrome, not lactose intolerance.

3. The patient who has two fractured ribs from an automobile accident is receiving discharge teaching. Which statement by the patient indicates effective teaching?

• A. I am going to buy a rib binder to wear during the day.
• B. I can take shallow breaths to prevent my chest from hurting.
• C. I should plan on taking the pain pills only at bedtime so I can sleep.
• D. I will use the incentive spirometer every hour or two during the day.

Correct answer: D

Rationale: The correct answer is, 'I will use the incentive spirometer every hour or two during the day.' After sustaining rib fractures, it is crucial to prevent complications like atelectasis and pneumonia by practicing deep breathing and coughing. Using the incentive spirometer helps in maintaining lung expansion and preventing respiratory issues. Buying a rib binder could restrict chest expansion and hinder deep breathing efforts, increasing the risk of atelectasis. Taking shallow breaths may not effectively expand the lungs, leading to potential respiratory complications. Relying solely on pain medication at bedtime may not adequately address the need for lung expansion and prevention of respiratory complications during the day.

4. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

• A. Unequal leg length
• B. Limited adduction
• C. Diminished femoral pulses
• D. Symmetrical gluteal folds

Correct answer: A

Rationale: In developmental dysplasia of the hip (DDH), one of the key findings is unequal leg length. This occurs due to the dislocation of the hip joint, where the ball is loose in the socket. Limited adduction, the inability to bring the hip and knee towards the midline of the body, is also a common finding in DDH. Diminished femoral pulses are not typically associated with DDH, as it primarily affects the skeletal structure rather than vascular supply. Symmetrical gluteal folds are normal in infants and do not indicate DDH, as asymmetry in gluteal folds can be a sign of hip dislocation.

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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