Nursing Elites

1. Three major causes of atherosclerosis are:

• A. Hyperthyroidism, underweight, and poor appetite
• B. High blood cholesterol, high blood pressure, and cigarette smoking
• C. Constipation, peptic ulcer disease, and pancreatitis
• D. Kidney failure, edema, and sodium retention

Correct answer: B

Rationale: Atherosclerosis is primarily caused by high blood cholesterol, high blood pressure, and cigarette smoking. These factors contribute to the buildup of plaque in the arteries. Choices A, C, and D are incorrect. Hyperthyroidism, underweight, and poor appetite do not directly cause atherosclerosis. Similarly, constipation, peptic ulcer disease, pancreatitis, kidney failure, edema, and sodium retention are not among the primary causes of atherosclerosis.

2. Which outcome should the nurse identify for the client diagnosed with fluid volume excess?

• A. The client will void a minimum of 30 mL per hour
• B. The client will have elastic skin turgor
• C. The client will have no adventitious breath sounds
• D. The client will have a serum creatinine of 1.4 mg/dL

Correct answer: C

Rationale: The correct outcome for a client diagnosed with fluid volume excess is the absence of adventitious breath sounds. This indicates that fluid is not accumulating in the lungs, a crucial sign in managing fluid volume excess. Choices A, B, and D are incorrect because voiding a specific amount of urine, having elastic skin turgor, and a serum creatinine level do not directly relate to managing fluid volume excess.

3. The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

• A. The client with an abdominal aortic aneurysm who is constipated
• B. The client on bed rest who ambulated to the bathroom
• C. The client with essential hypertension who has epistaxis and a headache
• D. The client with arterial occlusive disease who has a decreased pedal pulse

Correct answer: C

Rationale: The correct answer is C because epistaxis and headache in a client with hypertension are signs of a hypertensive crisis that necessitate immediate intervention. Choice A is incorrect as constipation in a client with an abdominal aortic aneurysm, while important, does not indicate an immediate crisis. Choice B is incorrect as a client on bed rest ambulating to the bathroom is a positive sign. Choice D is incorrect because a decreased pedal pulse in arterial occlusive disease should be addressed promptly, but it does not indicate an acute emergency like a hypertensive crisis.

4. Six hours after major abdominal surgery, a male client complains of severe abdominal pain; is pale and perspiring; has a thready, rapid pulse; and states he feels faint. The nurse checks the client’s medication administration record and determines that the client receives another injection of pain medication in an hour. What is the appropriate action by the nurse?

• A. Explain to the client that it is too early to have an injection for pain
• B. Call the practitioner, report the client’s symptoms, and obtain further orders
• C. Reposition the client for greater comfort and turn on the television as a distraction
• D. Prepare the injection and administer it to the client early because of the severe pain

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is option B: Call the practitioner, report the client’s symptoms, and obtain further orders. The client is displaying symptoms that indicate potential complications, such as internal bleeding, which require immediate medical evaluation. Option A is incorrect because the client's condition suggests a more urgent need for assessment. Option C is inappropriate as it does not address the seriousness of the client's symptoms. Option D is dangerous and could exacerbate any underlying issue the client may be experiencing.

5. The nurse writes a problem of “potential for complication related to ovarian hyperstimulation” for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?

• A. Instruct the client to delay intercourse until menses
• B. Schedule the client for frequent pelvic sonograms
• C. Explain that the infusion therapy will take 21 days
• D. Discuss that this may cause an ectopic pregnancy

Correct answer: B

Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (Choice A) is not directly related to monitoring for ovarian hyperstimulation. Explaining the duration of infusion therapy (Choice C) is not relevant to monitoring for this specific complication. Discussing the risk of ectopic pregnancy (Choice D) is important, but it is not the most appropriate intervention for monitoring ovarian hyperstimulation.

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