Nursing Elites

1. What lab value should be prioritized in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. White blood cell count
• C. Serum albumin levels
• D. Hemoglobin levels

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A count below 180 cells/mm3 signifies severe immunocompromise and an increased risk of opportunistic infections. Choices B, C, and D are not the priority lab values in HIV management. While white blood cell count, serum albumin levels, and hemoglobin levels are important, they do not directly reflect the immune status and progression of HIV as the CD4 T-cell count does.

2. What should the healthcare provider do if a patient presents with chest pain and possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Administer aspirin
• C. Obtain cardiac enzymes
• D. Get IV access and auscultate heart sounds

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority action in the treatment of chest pain in acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain. Aspirin can also be given to reduce clot formation, but nitroglycerin takes precedence in providing immediate relief. Obtaining cardiac enzymes and assessing heart sounds are important steps in the diagnostic process but do not address the immediate need to relieve chest pain and prevent cardiac tissue damage. Therefore, administering sublingual nitroglycerin is the most appropriate initial intervention for a patient presenting with chest pain and possible acute coronary syndrome.

3. What should the nurse do when a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. Lowering the height helps relieve cramping by slowing down the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is incorrect as it does not directly address the cramping issue. Choice C, continuing the enema at a slower rate, could potentially worsen the cramping by prolonging the discomfort. Choice D, increasing the flow of the enema solution, is also incorrect as it may intensify the cramping and cause more discomfort to the patient.

4. What are the signs and symptoms of a hemorrhagic stroke?

• A. Sudden severe headache, decreased level of consciousness, and seizures
• B. Loss of consciousness and weakness
• C. Temporary vision loss
• D. Severe chest pain and shortness of breath

Correct answer: A

Rationale: The correct answer is A. A hemorrhagic stroke often presents with a sudden severe headache, decreased level of consciousness, and seizures due to bleeding in the brain. Choice B, loss of consciousness and weakness, is more indicative of an ischemic stroke where a clot blocks blood flow to the brain. Choice C, temporary vision loss, is more commonly seen in conditions like transient ischemic attacks (TIAs) or retinal migraines. Choice D, severe chest pain and shortness of breath, are symptoms more associated with cardiac issues like a heart attack.

5. What is the priority nursing action when a patient with chest pain presents with possible acute coronary syndrome?

• A. Administer sublingual nitroglycerin
• B. Obtain IV access
• C. Check the patient's cardiac enzymes
• D. Administer aspirin

Correct answer: A

Rationale: The priority nursing action when a patient with chest pain presents with possible acute coronary syndrome is to administer sublingual nitroglycerin. Sublingual nitroglycerin helps dilate blood vessels, reducing cardiac workload, and improving blood supply to the heart muscle, thus relieving pain and enhancing blood flow to the heart. While obtaining IV access is important for administering medications and fluids, it is not the priority over addressing pain and improving blood flow. Checking the patient's cardiac enzymes is crucial for diagnosis and ongoing management but not the immediate priority when the patient is in pain. Administering aspirin is also a vital intervention in acute coronary syndrome, but in this scenario, it is not the priority action compared to providing immediate pain relief and enhancing blood flow to the heart.

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