Nursing Elites

1. A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?

• A. Monitor the client’s skin for rash and lesions.
• B. Monitor for signs of increased intracranial pressure.
• C. Monitor the client’s blood pressure closely.
• D. Monitor for changes in heart rate and rhythm.

Correct answer: B

Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client’s skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.

2. After a thyroidectomy, which vital sign is the most important for the nurse to monitor closely?

• A. Monitor respiratory rate and rhythm.
• B. Assess for signs of hypocalcemia.
• C. Monitor for elevated body temperature.
• D. Check blood pressure every 30 minutes.

Correct answer: B

Rationale: The correct answer is B: Assess for signs of hypocalcemia. After a thyroidectomy, monitoring for hypocalcemia is crucial because damage to the parathyroid glands during surgery can result in low calcium levels, which may cause life-threatening complications. Monitoring respiratory rate and rhythm (choice A) is important but not the most critical in this situation. Monitoring for elevated body temperature (choice C) is less of a priority post-thyroidectomy. Checking blood pressure every 30 minutes (choice D) is not as vital as monitoring for hypocalcemia in this context.

3. A client is admitted with a large bowel obstruction. What finding should the nurse report immediately?

• A. Absence of bowel sounds in all four quadrants.
• B. Abdominal distention with a firm, rigid abdomen.
• C. Frequent, small, liquid stools.
• D. Nausea and vomiting that worsens after meals.

Correct answer: B

Rationale: Abdominal distention with a firm, rigid abdomen is a concerning sign that may indicate perforation, which requires immediate intervention. The rigidity suggests a complication of the large bowel obstruction. Absence of bowel sounds in all four quadrants, option A, is a common finding in a bowel obstruction but not as alarming as a rigid abdomen. Frequent, small, liquid stools, option C, are not typical findings in a large bowel obstruction; instead, constipation is more common. Nausea and vomiting that worsens after meals, option D, are also common symptoms of a bowel obstruction but do not indicate an immediate life-threatening complication like a perforation.

4. A client with type 1 diabetes is found unconscious with a blood glucose of 40 mg/dL. What is the nurse's priority intervention?

• A. Administer a 50% dextrose bolus intravenously.
• B. Administer glucagon intramuscularly.
• C. Provide oral glucose gel.
• D. Recheck the blood glucose level in 15 minutes.

Correct answer: A

Rationale: The correct answer is to administer a 50% dextrose bolus intravenously. In unconscious clients with hypoglycemia, IV dextrose rapidly raises the blood glucose level. Glucagon would be a slower option and is typically used if IV access is unavailable. Oral glucose gel is not appropriate for an unconscious client as it requires swallowing and may cause aspiration. Rechecking the blood glucose level in 15 minutes delays immediate treatment and could lead to further deterioration.

5. A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Blood glucose 90 mg/dL
• B. Sodium 138 mEq/L
• C. Total calcium 5.0 mg/dL
• D. Potassium 4.2 mEq/L

Correct answer: C

Rationale: A total calcium level of 5.0 mg/dL is critically low and indicates possible hypocalcemia, a common complication after thyroid surgery. This condition can lead to tetany and requires immediate intervention. Blood glucose within normal range, sodium, and potassium levels are not indicative of an immediate postoperative complication like hypocalcemia in this case.

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