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 client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?

• A. Increase the oxygen flow rate to 4 liters per minute.
• B. Instruct the client to rest until the oxygen saturation improves.
• C. Discontinue ambulation and return the client to bed.
• D. Encourage the client to breathe more deeply.

Correct answer: C

Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.

3. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?

• A. Check for any abrasions or bruises.
• B. Help the client to stand.
• C. Get a blood pressure cuff.
• D. Report the fall to the nurse-manager.

Correct answer: C

Rationale: The correct task for the nurse to ask the unlicensed assistive personnel (UAP) to do in this situation is to "Get a blood pressure cuff." This is important because assessing the client's vital signs, including blood pressure, is crucial after a fall to ensure there are no underlying issues like hypotension. Choices A and B may be important tasks for the nurse to perform as part of the assessment and care of the client. However, in this scenario, the immediate concern should be to check the client's blood pressure. Choice D is not the most urgent task at this time, as assessing the client's condition takes precedence.

4. A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement?

• A. Notify the healthcare provider.
• B. Review the client's medication history.
• C. Prepare the client for thyroid function tests.
• D. Initiate seizure precautions.

Correct answer: A

Rationale: In a scenario where a client with hyperthyroidism is not responding to medications, the nurse's priority action should be to notify the healthcare provider. This is important because the client may require immediate intervention, such as adjusting the treatment plan or exploring alternative therapies. Reviewing the client's medication history (choice B) may be relevant but not as urgent as involving the healthcare provider. While preparing the client for thyroid function tests (choice C) may be necessary as part of the evaluation process, it is not the most immediate action to take. Initiating seizure precautions (choice D) is not directly related to the non-responsiveness of medications in hyperthyroidism and is not a priority in this situation.

5. In a client with cirrhosis admitted with jaundice and ascites, which laboratory value is most concerning?

• A. Serum bilirubin of 3.0 mg/dl
• B. Serum albumin of 3.0 g/dl
• C. Serum ammonia level of 80 mcg/dl
• D. Serum sodium level of 135 mEq/L

Correct answer: C

Rationale: A serum ammonia level of 80 mcg/dl is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. Elevated ammonia levels are associated with impaired liver function and can lead to mental status changes. Serum bilirubin (Choice A) is elevated in cirrhosis but not as concerning for acute intervention as high ammonia levels. Serum albumin (Choice B) and serum sodium (Choice D) levels are important in cirrhotic patients but are not as directly associated with hepatic encephalopathy as ammonia levels.

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