Nursing Elites

1. Which hormone is responsible for amenorrhea in the pregnant woman?

• A. Progesterone
• B. Estrogen
• C. Follicle-stimulating hormone (FSH)
• D. Human chorionic gonadotropin (hCG)

Correct answer: A

Rationale: Correct! Progesterone is the hormone responsible for amenorrhea in pregnant women. Progesterone plays a crucial role in maintaining the uterine lining for implantation and supporting early pregnancy. High levels of progesterone during pregnancy suppress the normal menstrual cycle, leading to amenorrhea. Estrogen, FSH, and hCG do not directly cause amenorrhea in pregnant women. Estrogen is involved in the development of female secondary sexual characteristics, FSH is involved in the growth and maturation of ovarian follicles, and hCG is produced by the placenta to support the production of progesterone during pregnancy.

2. The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?

• A. irregular respirations
• B. abdominal respirations
• C. shallow respirations
• D. 70 breaths per minute

Correct answer: D

Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.

3. A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse anticipates that this client would be in which acid-base imbalance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: B

Rationale: The correct answer is respiratory alkalosis. Hyperventilation due to anxiety, pain, shock, severe infection, fever, or liver failure can lead to respiratory alkalosis. In this scenario, the client is extremely anxious and crying uncontrollably, indicating an increased respiratory rate and CO2 loss. Respiratory acidosis (choice A) is incorrect as it is characterized by an increase in CO2 levels, not a loss. Metabolic acidosis (choice C) involves a decrease in blood pH due to an accumulation of acids or loss of bicarbonate, which is not the case here. Metabolic alkalosis (choice D) results from excess bicarbonate or a loss of acids, not from increased CO2 loss due to hyperventilation.

4. Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?

• A. Transfuse neutrophils (granulocytes) to prevent infection.
• B. Exclude raw vegetables from the diet.
• C. Avoid administering rectal suppositories.
• D. Prohibit vases of fresh flowers and plants in the client's room.

Correct answer: A

Rationale: The correct answer is to transfuse neutrophils (granulocytes) to prevent infection. Granulocyte transfusion is not routinely indicated to prevent infection in neutropenic clients. While neutrophils are essential in fighting infections and are beneficial in selected populations of infected, severely granulocytopenic clients who do not respond to antibiotics and are expected to experience prolonged suppression of granulocyte production, routine granulocyte transfusion is not recommended. Choices B, C, and D are appropriate interventions for a severely neutropenic client. Prohibiting fresh flowers and plants helps reduce the risk of exposure to environmental pathogens. Avoiding rectal suppositories minimizes the risk of introducing harmful bacteria. Excluding raw vegetables from the diet reduces the likelihood of foodborne infections.

5. For a client with suspected appendicitis, in which quadrant should the nurse expect to find abdominal tenderness?

• A. upper right
• B. upper left
• C. lower right
• D. lower left

Correct answer: C

Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic sign of appendicitis. The appendix is located in the lower right abdomen, so inflammation of the appendix typically causes tenderness in this specific area. Choices A, B, and D are incorrect because tenderness in the upper right, upper left, and lower left quadrants, respectively, is not typical in appendicitis cases. Therefore, the nurse should focus on assessing the lower right quadrant for tenderness when suspecting appendicitis.

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