Nursing Elites

1. Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)

• A. Greater than 1000 cells per deciliter
• B. Less than 500 cells per deciliter
• C. Greater than 2000 cells per deciliter
• D. Less than 200 cells per deciliter

Correct answer: D

Rationale: A T4 cell count of less than 200 cells per deciliter indicates symptomatic AIDS. This severe depletion of T4 cells signifies advanced HIV infection and a significantly compromised immune system. Choices A, B, and C are incorrect because T4 cell counts above 2000, above 1000, or below 500 cells per deciliter, respectively, are not indicative of symptomatic AIDS.

2. The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?

• A. Client with irritable bowel syndrome
• B. Family history of colon polyps
• C. Client with cirrhosis of the liver
• D. History of colon surgery

Correct answer: B

Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.

3. The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?

• A. Asterixis
• B. Hypertension
• C. Kussmaul respirations
• D. Lethargy

Correct answer: A

Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.

4. Which of the following symptoms is most characteristic of a client with lung cancer?

• A. exertional dyspnea
• B. persistent changing cough
• C. air hunger; dyspnea
• D. cough with night sweats

Correct answer: B

Rationale: The most characteristic symptom of lung cancer is a persistent changing cough. This cough may worsen over time and may produce blood-tinged sputum. Exertional dyspnea (Choice A) is more common in chronic obstructive pulmonary disease (COPD) due to airway obstruction. Air hunger and dyspnea (Choice C) are more typical of conditions like asthma. Cough with night sweats (Choice D) is commonly associated with tuberculosis rather than lung cancer.

5. A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?

• A. Notify the doctor
• B. Empty the drain
• C. Do nothing
• D. Remove the drain

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.

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