Nursing Elites

1. When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?

• A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
• B. Risk for injury related to active loss of blood from the vascular space
• C. Deficient knowledge related to the client's lack of understanding of the disease process
• D. Impaired skin integrity related to the development of bruises and/or hematoma

Correct answer: B

Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.

2. A patient had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?

• A. Decreased breath sound volume
• B. Elevated tidal volume
• C. Elevated respiratory capacity
• D. Wheezing

Correct answer: A

Rationale: After a pneumonectomy, where a lung is surgically removed, there will be a decrease in breath sound volume on the affected side due to reduced airflow. This reduction in breath sound volume is expected as there is less lung tissue to produce sound. Choices B, C, and D are incorrect. Elevated tidal volume and respiratory capacity are not expected after a pneumonectomy, and wheezing is more commonly associated with conditions like asthma or bronchitis, not a recent pneumonectomy.

3. A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first?

• A. Instruct the child to extend the affected knee
• B. Perform range of motion exercises on both knees
• C. Compare the appearance of the left knee to the right knee
• D. Have the child soak the affected knee in warm water

Correct answer: C

Rationale: Comparing the appearance of the left knee to the right knee is the most appropriate initial action as it provides a baseline for assessing any visible differences such as swelling, bruising, or deformities. This comparison helps the nurse identify any acute changes in the affected knee's appearance after the fall. Instructing the child to extend the affected knee (Choice A) may worsen the pain or cause further injury. Performing range of motion exercises on both knees (Choice B) could exacerbate the pain and should be avoided until a proper assessment is done. Having the child soak the affected knee in warm water (Choice D) is not the priority at this stage as assessing for any physical changes is more crucial.

4. When dressing a severe burn to the right hand, it is important for the nurse to:

• A. Apply a wet-to-dry dressing for debridement
• B. Wrap each digit individually to prevent webbing
• C. Open blisters to allow drainage prior to dressing
• D. Allow the client to do as much of the dressing change as possible

Correct answer: B

Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.

5. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by

• A. the kidneys' inability to excrete the drug metabolites.
• B. rapid cell catabolism.
• C. toxic effects of the prophylactic antibiotics given concurrently.
• D. the altered blood pH from the acidic nature of the drugs.

Correct answer: B

Rationale: The correct answer is 'rapid cell catabolism.' Chemotherapy leads to the destruction of cells, resulting in increased uric acid levels due to cell breakdown. Choice A is incorrect because the issue is not with the kidneys' ability to excrete the drug metabolites but rather with the cell breakdown. Choice C is incorrect as the question focuses on chemotherapy and its effects, not prophylactic antibiotics. Choice D is incorrect as the question pertains to the development of high uric acid levels, not altered blood pH from acidic drugs.

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