Nursing Elites

1. 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.

2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?

• A. Difference in the intake and output
• B. Changes in the mucous membranes
• C. Skin turgor
• D. Weekly weight

Correct answer: D

Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.

3. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?

• A. Ensure that the restraint is snug against the client’s wrist.
• B. Reposition the restraint tie onto the bedframe.
• C. Double knot the restraint to ensure safety.
• D. Leave the restraint in place and notify the healthcare provider.

Correct answer: B

Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.

4. The nurse is providing discharge teaching to a client with asthma. Which statement indicates the client understands how to use a rescue inhaler?

• A. I will use my rescue inhaler every morning to prevent asthma attacks.
• B. I should use my rescue inhaler when I start to experience wheezing.
• C. I will use my rescue inhaler when my peak flow meter reading is in the green zone.
• D. I will only use my rescue inhaler before going to bed.

Correct answer: B

Rationale: The correct answer is B: 'I should use my rescue inhaler when I start to experience wheezing.' A rescue inhaler is used during the onset of asthma symptoms, such as wheezing, to quickly open the airways. It is not intended for routine daily use or prevention, which is the role of a maintenance inhaler. Option A is incorrect because a rescue inhaler is not used for prevention but for immediate relief during an asthma attack. Option C is incorrect because the peak flow meter reading is used to monitor asthma control, not to determine when to use a rescue inhaler. Option D is incorrect because using a rescue inhaler only before going to bed does not address the need for immediate relief when wheezing or experiencing asthma symptoms.

5. Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

• A. Balance and coordination
• B. Cognitive status
• C. Level of pain
• D. Upper body muscle strength

Correct answer: D

Rationale: The correct answer is D: Upper body muscle strength. The ability to use a trapeze bar requires adequate upper body strength to support the weight and facilitate repositioning. While assessing pain, coordination, and cognitive status are important, the priority is determining if the client can physically manage the trapeze bar safely. Without sufficient upper body muscle strength, the client may not be able to use the trapeze bar effectively and safely. Assessing balance and coordination is also important but secondary to ensuring the client has the required upper body strength. Cognitive status is crucial for understanding instructions related to using the trapeze bar, but it is not the most critical assessment in this scenario. Pain assessment is essential for overall care but does not directly impact the client's ability to use a trapeze bar like upper body muscle strength does.

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