Nursing Elites

1. Which laboratory test result should the nurse monitor to evaluate the effects of therapy for a 62-year-old female patient with acute pancreatitis?

• A. Calcium
• B. Bilirubin
• C. Amylase
• D. Potassium

Correct answer: C

Rationale: The correct answer is C: Amylase. In acute pancreatitis, amylase levels are typically elevated. Monitoring amylase levels helps assess the effectiveness of therapy in managing the condition. Elevated amylase is a key indicator of pancreatic inflammation. Calcium (Choice A) levels may be affected in pancreatitis, but they are not the primary indicator for evaluating therapy effectiveness. Bilirubin (Choice B) and Potassium (Choice D) levels may also be altered in pancreatitis, but they are not specific markers for monitoring therapy response in acute pancreatitis.

2. When assessing a child admitted to the hospital with pyloric stenosis, which symptom would the nurse likely find when asking the parent about the child's symptoms?

• A. Watery diarrhea
• B. Projectile vomiting
• C. Increased urine output
• D. Vomiting large amounts of bile

Correct answer: B

Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. The hallmark symptom of pyloric stenosis is projectile vomiting, which is the forceful expulsion of stomach contents. Other common symptoms include irritability, hunger and crying, constipation, and signs of dehydration. Watery diarrhea (Choice A) is not a typical symptom of pyloric stenosis. Increased urine output (Choice C) is not directly associated with this condition. Vomiting large amounts of bile (Choice D) is not a characteristic symptom of pyloric stenosis; instead, the vomitus in pyloric stenosis is non-bilious.

3. Which oxygen delivery system would provide the highest concentrations of oxygen to the client?

• A. Venturi mask
• B. Partial rebreather mask
• C. Non-rebreather mask
• D. Simple face mask

Correct answer: C

Rationale: The correct answer is the non-rebreather mask. This oxygen delivery system has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent the inhalation of room air but allow exhalation of air. When a tight seal is achieved around the mask, up to 100% of oxygen is available. Choice A, the Venturi mask, delivers precise oxygen concentrations but not as high as the non-rebreather mask. Choice B, the partial rebreather mask, allows the client to rebreathe some exhaled air, resulting in lower oxygen concentrations than the non-rebreather mask. Choice D, the simple face mask, delivers low to moderate oxygen concentrations and is not designed to provide the highest concentrations like the non-rebreather mask.

4. An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

• A. Yellow-tinged skin
• B. Orange-colored sputum
• C. Thickening of the fingernails
• D. Difficulty hearing high-pitched voices

Correct answer: A

Rationale: The correct answer is 'Yellow-tinged skin.' Yellow-tinged skin is indicative of noninfectious hepatitis, a toxic effect of isoniazid (INH), rifampin, and pyrazinamide. If a patient on TB therapy develops hepatotoxicity, alternative medications will be necessary. Thickening of fingernails and difficulty hearing high-pitched voices are not typical side effects of the medications used in standard TB therapy. Presbycusis, age-related hearing loss, is common in older adults and not a cause for immediate concern. Orange-colored sputum is an expected side effect of rifampin and does not warrant immediate notification to the healthcare provider.

5. A patient has taken an overdose of aspirin. Which of the following should a nurse closely monitor during acute management of this patient?

• A. Onset of pulmonary edema
• B. Metabolic alkalosis
• C. Respiratory alkalosis
• D. Parkinson's disease type symptoms

Correct answer: A

Rationale: The correct answer is to monitor the onset of pulmonary edema. In cases of aspirin overdose, metabolic acidosis is a common consequence that can lead to the development of pulmonary edema. Early signs of aspirin poisoning include symptoms like tinnitus, hyperventilation, vomiting, dehydration, and fever. Late signs may manifest as drowsiness, bizarre behavior, unsteady walking, and coma. Aspirin poisoning can cause abnormal breathing that is typically rapid and deep. Pulmonary edema may occur due to increased capillary permeability in the lungs, leading to the leakage of proteins and fluid transudation in renal and pulmonary tissues. Changes in renal tubule permeability can also affect colloid osmotic pressure, potentially contributing to pulmonary edema. Monitoring pulmonary edema is crucial in managing aspirin overdose cases to prevent further complications. Choices B, C, and D are incorrect because metabolic alkalosis, respiratory alkalosis, and Parkinson's disease type symptoms are not typically associated with aspirin overdose and are not primary concerns in its acute management.

Similar Questions