Nursing Elites

1. The nurse is aware that norepinephrine is secreted by which endocrine gland?

• A. The pancreas
• B. The adrenal cortex
• C. The adrenal medulla
• D. The anterior pituitary gland

Correct answer: C

Rationale: The correct answer is C: The adrenal medulla. Norepinephrine is secreted by the adrenal medulla and is involved in the body's 'fight or flight' response. The pancreas (choice A) secretes insulin and glucagon, not norepinephrine. The adrenal cortex (choice B) secretes hormones like cortisol and aldosterone, but not norepinephrine. The anterior pituitary gland (choice D) secretes various hormones like growth hormone and thyroid-stimulating hormone, but not norepinephrine.

2. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

• A. Assess the client’s vital signs
• B. Start an IV with an 18-gauge needle
• C. Begin iced saline lavage
• D. A, B

Correct answer: D

Rationale: In this scenario, the client's presentation of acute epigastric pain and vomiting bright red blood indicates a potential gastrointestinal bleeding emergency. Assessing the client's vital signs is essential to monitor their hemodynamic status. Starting an IV with an 18-gauge needle is crucial to establish access for potential fluid resuscitation or blood transfusion. Beginning iced saline lavage is not appropriate in this situation and could potentially delay necessary interventions. Therefore, the correct interventions for the nurse to implement are to assess the client’s vital signs and start an IV, making option D the most appropriate choice. Options A and B are correct because they are essential initial steps in managing gastrointestinal bleeding. Option C is incorrect as iced saline lavage is not indicated and may not address the urgent needs of the client in this critical situation.

3. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

• A. The client’s BP is 110/70
• B. The client’s potassium level is 3.4 mEq/L
• C. The client has a barky cough
• D. The client’s apical pulse is 56

Correct answer: D

Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering the medication as the blood pressure is within a normal range for a client with essential hypertension. Choice B is not directly related to the administration of a beta blocker. Choice C suggests a potential side effect of an ACE inhibitor, not a beta blocker.

4. The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

• A. Assist the client in ambulating
• B. Assess the client's bilateral pedal pulses
• C. Maintain a continuous IV heparin drip
• D. Provide clear liquids to the client

Correct answer: B

Rationale: Assessing the client's bilateral pedal pulses is essential in this situation as it helps in evaluating the peripheral perfusion and circulation in the lower extremities. This assessment is crucial to detect any signs of decreased blood flow or complications, such as arterial occlusion or thrombosis. Ambulating the client may be important in the postoperative period, but assessing pedal pulses takes priority to ensure adequate perfusion. Maintaining continuous IV heparin drip is not typically indicated immediately post-operatively for an abdominal aortic aneurysm repair, as the risk of bleeding complications may outweigh the benefits. Providing a clear liquid diet is not a priority nursing intervention at this stage, as the focus should be on vascular assessment and postoperative monitoring.

5. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to implement when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. Leaning forward can help bring the heart closer to the chest wall, making it easier to detect the rub. Option A (Notifying the healthcare provider) is incorrect because further assessment is needed before escalating the situation. Option B (Documenting that the pericarditis has resolved) is incorrect as the absence of a friction rub does not necessarily mean resolution. Option D (Preparing to insert a unilateral chest tube) is incorrect as this intervention is not indicated for the absence of a friction rub.

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