Nursing Elites

1. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?

• A. Determine if the client has also experienced breast tenderness and weight gain.
• B. Encourage the client to begin a regular, daily program of walking and exercise.
• C. Advise the client to notify the healthcare provider for immediate medical attention.
• D. Tell the client to stop taking the medication for a week to see if symptoms subside.

Correct answer: C

Rationale: Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.

2. A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply.

• A. Hematocrit 30%
• B. Sodium 141 mEq/L
• C. Hemoglobin 8.9 g/dL
• D. Platelets 210,000 cells/mm3

Correct answer: C

Rationale: The correct answer is C. Hemoglobin level of 8.9 g/dL is below the normal range, indicating anemia. Anemia can affect the body's ability to carry oxygen, impacting surgical outcomes. Hematocrit level is an indirect measure of red blood cells, which also reveals anemia when low. Sodium level of 141 mEq/L and platelet count of 210,000 cells/mm3 are within normal ranges and do not require immediate reporting. Abnormal sodium levels can lead to various issues, but in this scenario, it is not a concern for surgical readiness. Platelet count is vital for blood clotting, and a count of 210,000 cells/mm3 is considered normal, so it does not need urgent attention.

3. Why is lactated Ringer’s solution given to a patient experiencing vomiting and diarrhea?

• A. To increase interstitial and intracellular hydration
• B. To maintain plasma volume over time
• C. To pull water from the interstitial space into the extracellular fluid
• D. To replace water and electrolytes

Correct answer: D

Rationale: Lactated Ringer’s solution is an isotonic solution commonly used to replace water and electrolytes lost due to conditions like vomiting and diarrhea. It helps to restore fluid balance by replacing the lost volume and electrolytes. Option A is incorrect because hypotonic fluids, not lactated Ringer’s solution, increase interstitial and intracellular hydration. Option B is incorrect as colloidal solutions, not lactated Ringer’s solution, are used to maintain plasma volume over time. Option C is incorrect as hypertonic solutions, not lactated Ringer’s solution, pull water from the interstitial space into the extracellular fluid.

4. A client recovering from extracorporeal shock wave lithotripsy for renal calculi has an ecchymotic area on the right lower back. What action should the nurse take?

• A. Administer fresh-frozen plasma.
• B. Apply an ice pack to the site.
• C. Place the client in the prone position.
• D. Obtain serum coagulation test results.

Correct answer: B

Rationale: After extracorporeal shock wave lithotripsy, ecchymosis can occur due to bleeding into the tissues from the shock waves. Applying an ice pack helps reduce the extent and discomfort of bruising. Administering fresh-frozen plasma and obtaining coagulation test results are not necessary as ecchymosis after this procedure is common and does not indicate a bleeding disorder that requires immediate intervention. Placing the client in the prone position will not address the bleeding or bruising in this situation.

5. Which of the following is a key symptom of hypothyroidism?

• A. Weight loss.
• B. Heat intolerance.
• C. Cold intolerance.
• D. Increased appetite.

Correct answer: C

Rationale: Cold intolerance is a key symptom of hypothyroidism because a decreased metabolic rate leads to a reduced ability to regulate body temperature. Weight loss (Choice A) is more commonly associated with hyperthyroidism, where the metabolic rate is increased. Heat intolerance (Choice B) is also more indicative of hyperthyroidism, where excess thyroid hormone leads to an increased sensitivity to heat. Increased appetite (Choice D) is not typically seen in hypothyroidism; instead, individuals with hypothyroidism may experience weight gain due to the slowed metabolism.

Similar Questions