Nursing Elites

1. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

• A. Check the visual difficulties
• B. Note the most recent hemoglobin level
• C. Assess for hand and joint pain
• D. Observe rhythm on telemetry monitor

Correct answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

2. A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, 'Is my friend who was in the car with me ok?' What response is best for the nurse to provide?

• A. I am sorry, but your friend was killed in the accident.
• B. Right now you need to concentrate on getting well.
• C. Was the passenger in the car your friend?
• D. I think your friend is going to be all right.

Correct answer: A

Rationale: The correct answer is A: 'I am sorry, but your friend was killed in the accident.' In this situation, honesty and compassion are essential. The nurse should provide the client with truthful information, acknowledging the client's need to know the reality of the situation. Choice B is dismissive and does not address the client's inquiry directly. Choice C is a deflecting question and does not offer the direct information the client is seeking. Choice D provides false reassurance, which is not appropriate in this circumstance where the reality needs to be communicated.

3. The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which intervention should the nurse implement first?

• A. Advance to clear liquids as tolerated
• B. Straight catheterization if unable to void
• C. Administer Cefazolin 1 gram IVPQ q6 hours
• D. Obtain a complete blood cell count (CBC) in the morning

Correct answer: B

Rationale: The correct answer is to perform straight catheterization if the client is unable to void. This action is essential to prevent urinary retention and its potential complications following anesthesia. Option A, advancing to clear liquids, is not the priority upon admission as the focus should be on urinary function first. Option C involves administering an antibiotic, which is important but not the immediate priority. Option D, obtaining a CBC, can be done later and is not as crucial as ensuring proper urinary function postoperatively.

4. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?

• A. Usual and current weight
• B. Color and amount of urine
• C. Number and frequency of stools
• D. Intake and output 24 hours prior to admission

Correct answer: A

Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.

5. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

• A. Altered consciousness within the first 24 hours after injury
• B. Confusion immediately following the injury
• C. Headache that resolves quickly
• D. Brief loss of consciousness with a lucid interval

Correct answer: A

Rationale: The correct answer is A. Epidural hematoma often presents with a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness. Therefore, altered consciousness within the first 24 hours after the injury is indicative of a developing epidural hematoma. Choices B, C, and D are incorrect because confusion immediately following the injury, headache that resolves quickly, and brief loss of consciousness with a lucid interval are not specific signs of epidural hematoma.

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