Nursing Elites

1. The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?

• A. The oxygen saturation is 94%.
• B. The blood pressure is 98/56 mm Hg.
• C. The patient's central IV line is disconnected.
• D. The international normalized ratio (INR) is prolonged.

Correct answer: C

Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.

2. A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful?

• A. The absence of special cells in the rectum caused the disease.
• B. Incomplete digestion of the protein part of wheat, barley, rye, and oats is not the cause of the disease.
• C. The disease does not occur due to increased bowel motility leading to spasm and pain.
• D. The disease is not caused by the inability to tolerate sugar found in dairy products.

Correct answer: A

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or megacolon, is characterized by the absence of ganglion cells in the rectum and, sometimes, extending into the colon. Choice A correctly explains the cause of Hirschsprung's disease. Choice B is incorrect as it describes celiac disease, which is related to gluten intolerance. Choice C is inaccurate as it describes symptoms of irritable bowel syndrome, not the cause of Hirschsprung's disease. Choice D is wrong as it pertains to lactose intolerance, not Hirschsprung's disease.

3. A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acid?'

• A. Green vegetables and liver
• B. Yellow vegetables and red meat
• C. Carrots
• D. Milk

Correct answer: A

Rationale: Green vegetables and liver are rich sources of folic acid. Green vegetables like spinach, asparagus, and broccoli are high in folic acid content. Liver, especially from chicken or beef, is also a good source of folic acid. Yellow vegetables and red meat (choice B) do not contain as high a concentration of folic acid as green vegetables and liver. Carrots (choice C) are nutritious but do not have the highest concentration of folic acid. Milk (choice D) is not a significant source of folic acid compared to green vegetables and liver.

4. The client is seven (7) days post total hip replacement. Which statement by the client requires the nurse's immediate attention?

• A. I have bad muscle spasms in my lower leg of the affected extremity.
• B. I just can't 'catch my breath' over the past few minutes and I think I am in grave danger.
• C. I have to use the bedpan to pass my water at least every 1 to 2 hours.
• D. It seems that the pain medication is not working as well today.

Correct answer: B

Rationale: While all statements by the client require attention, the most critical one that demands immediate action is option B. Clients who have undergone hip or knee surgery are at an increased risk of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are hallmark signs of this condition. Without appropriate prophylaxis such as anticoagulant therapy, deep vein thrombosis (DVT) can develop within 7 to 14 days after surgery, potentially leading to pulmonary embolism. It is crucial for the nurse to recognize signs of DVT, which include pain, tenderness, skin discoloration, swelling, or tightness in the affected leg. Signs of pulmonary embolism include sudden onset dyspnea, tachycardia, confusion, and pleuritic chest pain. Option B indicates a potentially life-threatening situation that requires immediate intervention to prevent serious complications.

5. The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother?

• A. You should use an orthodontic nipple on the child's bottle.
• B. You need to use a plastic spoon to feed the child.
• C. You can allow the child to use a pacifier but only for 30 minutes at a time.
• D. You need to monitor the child's temperature for signs of infection using an oral thermometer.

Correct answer: A

Rationale: After a cleft palate repair, it is crucial to use an orthodontic nipple on the child's bottle to feed them appropriately. The mother should be instructed to give the child baby food or baby food mixed with water. It is important to avoid introducing straws, pacifiers, spoons, or fingers into the child's mouth for 7 to 10 days post-surgery to prevent complications. The use of a pacifier should be avoided for at least 2 weeks following the surgical repair to promote proper healing. Additionally, taking oral temperatures should be avoided, and alternative temperature monitoring methods should be utilized to reduce the risk of infection. Therefore, options B, C, and D are incorrect because they could potentially lead to complications or hinder the child's recovery after cleft palate repair.

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