Nursing Elites

1. A client who has just returned from surgery is shivering uncontrollably. What is the best action for the nurse to take?

• A. Offer the client a warm blanket
• B. Apply warm blankets and monitor the client's temperature
• C. Place a warm blanket in the client's bed before transferring the client from the stretcher
• D. Administer a prescribed muscle relaxant

Correct answer: B

Rationale: Applying warm blankets and monitoring the client's temperature is the best action to manage postoperative shivering. Shivering after surgery can be a common response due to factors like exposure to cold, pain, or anesthesia effects. Providing warmth through blankets can help regulate the client's body temperature and alleviate shivering. Monitoring the client's temperature is essential to ensure it returns to a normal range. Option A is not as comprehensive as option B, which includes both providing warmth and monitoring the client. Option C is incorrect as it focuses on preparing the bed rather than addressing the client's immediate need for warmth. Option D is not appropriate without further assessment or prescription for a muscle relaxant to address shivering.

2. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

• A. Hypernatremia
• B. Excessive thirst
• C. Elevated heart rate
• D. Poor skin turgor

Correct answer: A

Rationale: The correct answer is A: Hypernatremia. In a client with Diabetes Insipidus, hypernatremia, an elevated sodium level in the blood, can lead to neurological symptoms such as confusion, seizures, or coma. Immediate intervention is necessary to prevent these serious complications. Excessive thirst (choice B) is a common symptom of Diabetes Insipidus but does not require immediate intervention. Elevated heart rate (choice C) and poor skin turgor (choice D) are important assessments but are not as critical as hypernatremia in this context.

3. The nurse is caring for a client with chronic heart failure who is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?

• A. Serum potassium of 3.0 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 1.8 mg/dL
• D. Blood glucose of 200 mg/dL

Correct answer: A

Rationale: A serum potassium level of 3.0 mEq/L is most concerning in a client receiving furosemide as it indicates hypokalemia, which requires immediate intervention. Hypokalemia can lead to serious cardiac arrhythmias, which can be life-threatening. Serum sodium of 135 mEq/L and serum creatinine of 1.8 mg/dL are within normal ranges and do not require immediate intervention in this case. Blood glucose of 200 mg/dL is elevated but does not pose an immediate threat to the client's life in the context of heart failure and furosemide therapy.

4. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be closely monitored before the procedure?

• A. Serum creatinine of 2.0 mg/dl
• B. Serum potassium of 5.5 mEq/L
• C. Serum calcium of 8.0 mg/dl
• D. Hemoglobin of 12 g/dl

Correct answer: B

Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, which can lead to serious cardiac complications. Hyperkalemia can be exacerbated during hemodialysis, making it crucial to closely monitor serum potassium levels before the procedure. Monitoring serum creatinine, serum calcium, or hemoglobin levels is important in managing ESRD but is not the immediate focus before hemodialysis. Therefore, option B is the correct choice.

5. The nurse who is working on a surgical unit receives a change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

• A. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.
• B. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain.
• C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
• D. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

Correct answer: D

Rationale: The correct answer is D. A client who had an abdominal-perineal resection 2 days ago with no drainage on the dressing but is presenting with fever and chills requires immediate attention. This presentation raises concerns for peritonitis, a serious complication that necessitates prompt assessment and intervention to prevent further complications. Choices A, B, and C do not indicate an immediate risk for a life-threatening condition like peritonitis, making them lower priority compared to choice D.

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