Nursing Elites

1. What is the hallmark sign of intussusception?

• A. Mucus-like stools
• B. Currant jelly-like stools
• C. Tarry, black stools
• D. Green, soft stools

Correct answer: B

Rationale: The hallmark sign of intussusception is currant jelly-like stools, which result from the mixture of blood and mucus in the stool due to the sloughing of intestinal mucosa. Mucus-like stools (Choice A) are not typically associated with intussusception. Tarry, black stools (Choice C) are characteristic of gastrointestinal bleeding higher up in the gastrointestinal tract, such as from a peptic ulcer. Green, soft stools (Choice D) are more indicative of rapid transit through the intestines, possibly due to dietary factors or infections such as gastroenteritis.

2. The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects?

• A. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
• B. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
• C. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
• D. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

Correct answer: B

Rationale: The correct answer is B: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. Tetralogy of Fallot involves these four congenital defects. Choice A is incorrect because it includes aortic stenosis instead of pulmonary stenosis, atrial septal defect instead of ventricular septal defect, and left ventricular hypertrophy instead of right ventricular hypertrophy. Choice C is incorrect as it includes aortic stenosis and atrial septal defect instead of pulmonary stenosis and ventricular septal defect. Choice D is incorrect because it includes aortic hypertrophy instead of overriding aorta.

3. A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the perioperative nurse prepare to implement first?

• A. Ensure patency of an indwelling catheter and measure hourly intake and output.
• B. Prepare for cessation of the anesthesia and the surgical procedure.
• C. Obtain specimens of ABGs and serum electrolytes.
• D. Initiate cooling measures using iced normal saline by nasogastric lavage.

Correct answer: B

Rationale: The correct answer is B: Prepare for cessation of the anesthesia and the surgical procedure. Malignant hyperthermia is a severe reaction to certain medications used during general anesthesia. The immediate intervention to manage malignant hyperthermia is to stop the triggering agents, which include anesthesia and surgery. Ensuring patency of an indwelling catheter and measuring intake and output, obtaining specimens of ABGs and serum electrolytes, and initiating cooling measures are important interventions but should follow the immediate action of stopping the anesthesia and surgery to address the life-threatening condition of malignant hyperthermia.

4. Which laboratory results should the nurse anticipate to be abnormal in a child with hemophilia?

• A. Prothrombin time
• B. Bleeding time
• C. Platelet count
• D. Partial thromboplastin time

Correct answer: D

Rationale: In a child with hemophilia, the nurse should anticipate an abnormality in the partial thromboplastin time (PTT) due to the deficiency in clotting factors. Prothrombin time, bleeding time, and platelet count are typically normal in hemophilia. Prothrombin time measures the extrinsic pathway of coagulation and is not affected in hemophilia. Bleeding time assesses platelet function, which is normal in hemophilia as the issue lies with clotting proteins, not platelets. Platelet count is also expected to be normal unless there is another underlying condition affecting platelet production or function.

5. What is the main characteristic of cystic fibrosis?

• A. Multiple upper respiratory infections
• B. An underproduction of exocrine glands
• C. Excessive, thick mucus
• D. An overproduction of thin mucus

Correct answer: C

Rationale: The main characteristic of cystic fibrosis is the production of excessive, thick mucus. This thick mucus leads to blockages in the airways, digestive system, and other organs. Choice A is incorrect because while individuals with cystic fibrosis are more prone to respiratory infections, the main characteristic is the mucus production. Choice B is incorrect as cystic fibrosis is characterized by the overproduction, not underproduction, of exocrine glands. Choice D is also incorrect as the mucus produced in cystic fibrosis is thick, not thin.

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