Nursing Elites

1. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is

• A. maintaining normal respiratory function.
• B. expressing satisfaction with pain control.
• C. developing no ongoing pancreatic disease.
• D. having adequate fluid and electrolyte balance.

Correct answer: A

Rationale: In acute severe pancreatitis, there is a risk of respiratory failure as a complication, making the maintenance of normal respiratory function the priority outcome. This patient may develop respiratory issues due to the inflammatory process affecting the diaphragm. While pain control, absence of ongoing pancreatic disease, and fluid/electrolyte balance are crucial, they are secondary to ensuring adequate oxygenation and ventilation to prevent respiratory compromise.

2. When admitting a 64-year-old patient with acute pancreatitis, the healthcare provider should specifically inquire about a history of

• A. diabetes mellitus.
• B. high-protein diet.
• C. cigarette smoking.
• D. alcohol consumption.

Correct answer: D

Rationale: In patients with acute pancreatitis, alcohol consumption is a significant risk factor and one of the most common causes in the United States. It is crucial to assess alcohol intake as it plays a key role in the development of pancreatitis. While cigarette smoking, diabetes mellitus, and high-protein diets can contribute to various health issues, they are not directly associated with the development of acute pancreatitis.

3. The healthcare provider is managing a 20 lbs (9 kg) 6-month-old with a 3-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be immediately reported to the healthcare provider?

• A. 3 episodes of vomiting in 1 hour.
• B. Periodic crying and irritability.
• C. Vigorous sucking on a pacifier.
• D. No measurable voiding in 4 hours.

Correct answer: D

Rationale: The critical finding that should be reported immediately to the healthcare provider is 'No measurable voiding in 4 hours.' This finding raises concerns about possible hyperkalemia, which can result from continued potassium administration and a decrease in urinary output. Hyperkalemia can lead to serious complications, including cardiac arrhythmias. The management of acute hyperkalemia involves interventions such as administering calcium to protect the heart, shifting potassium into cells, and enhancing potassium elimination from the body. The other choices do not indicate an urgent issue that requires immediate attention. Three episodes of vomiting in 1 hour can be concerning but may not be as immediately critical as the risk of hyperkalemia. Periodic crying and irritability are common in infants and may not indicate a severe complication. Vigorous sucking on a pacifier is a normal behavior in infants and does not signal a medical emergency.

4. The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit data associated with the cause of this disease?

• A. ''Has your child had any nausea or diarrhea?''
• B. ''Have you noticed any rashes on your child?''
• C. ''Did your child recently complain of a sore throat?''
• D. ''Did your child sustain any injuries to the kidney area?''

Correct answer: C

Rationale: The correct answer is 'Did your child recently complain of a sore throat?' Group A beta-hemolytic streptococcal infection is a known cause of glomerulonephritis. In this condition, the child typically becomes ill with streptococcal infection of the upper respiratory tract, and then after 1 to 2 weeks, symptoms of acute poststreptococcal glomerulonephritis can develop. This question aims to gather crucial information related to a potential trigger for glomerulonephritis. Choices A, B, and D are incorrect because they do not pertain to a common cause or associated symptom of glomerulonephritis.

5. A 33-year-old male client with heart failure has been taking furosemide for the past week. Which of the following assessment cues below may indicate the client is experiencing a negative side effect from the medication?

• A. Weight gain of 5 pounds
• B. Edema of the ankles
• C. Gastric irritability
• D. Decreased appetite

Correct answer: D

Rationale: The correct answer is 'Decreased appetite.' Furosemide is a loop diuretic used for conditions like heart failure, where it helps reduce fluid retention. One common side effect of furosemide is hypokalemia, which can lead to decreased appetite among other symptoms. Hypokalemia is a low level of potassium in the blood, and its signs and symptoms include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, and altered level of consciousness. Weight gain and ankle edema are actually expected outcomes of furosemide therapy due to its diuretic effect, which helps reduce edema and fluid overload. Gastric irritability is a nonspecific symptom that is not typically associated with furosemide use. Therefore, a decreased appetite is a key indicator of a potential negative side effect when assessing a client on furosemide therapy.

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