Nursing Elites

1. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Monitor urine output hourly
• B. Assess for back muscle aches
• C. Record drainage from the drain
• D. Obtain body weight daily

Correct answer: C

Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.

2. In what order should the nurse assess a lethargic one-hour-old infant brought to the nursery?

• A. Heel stick
• B. Respirations
• C. Heart rate
• D. Temperature

Correct answer: D

Rationale: When assessing a lethargic one-hour-old infant, the nurse should prioritize assessing the most critical parameters first. Temperature and heart rate are vital signs that provide immediate information about the infant's well-being. Therefore, the correct order of assessment should be temperature, heart rate, respirations, and then a heel stick. Temperature is crucial to determine if the infant is hypothermic or hyperthermic, while heart rate gives insight into the circulatory system's function. Respirations follow to evaluate the infant's breathing pattern. Lastly, the heel stick is important for certain screenings but is not as urgent as evaluating temperature and heart rate in a lethargic infant.

3. A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?

• A. Noncompliance with medication related to thought broadcasting
• B. Situational self-esteem disturbance secondary to schizophrenia
• C. Disturbed sensory perception related to auditory hallucinations
• D. Impaired environmental interpretation related to paranoid delusions

Correct answer: D

Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment. Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment. Choice B is incorrect as self-esteem disturbance is not the primary issue presented. Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.

4. What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS?

• A. Enlarged and tender cervical lymph nodes
• B. Presence of low-grade fever and sore throat
• C. Recent history of recurrent pneumonia
• D. CD4 blood cell count of 300

Correct answer: C

Rationale: The correct answer is C: 'Recent history of recurrent pneumonia.' Recurrent pneumonia is a hallmark indicator of progression to AIDS in clients with HIV infection. It signifies advanced immunosuppression when the body is unable to fight off infections effectively. Enlarged and tender cervical lymph nodes (Choice A) are more indicative of local infections or inflammation rather than AIDS progression. The presence of a low-grade fever and sore throat (Choice B) may be common in various infections and are not specific to AIDS progression. While a CD4 blood cell count of 300 (Choice D) is below the normal range and indicates immunosuppression, it alone may not be sufficient to suspect progression to AIDS without other supporting indicators like opportunistic infections such as recurrent pneumonia.

5. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

• A. Intravenous administration of thyroid hormones
• B. Oral administration of hypnotic agents
• C. Intravenous bolus of hydrocortisone
• D. Subcutaneous administration of vitamin K

Correct answer: A

Rationale: The correct answer is A: Intravenous administration of thyroid hormones. Myxedema coma is a severe form of hypothyroidism that necessitates immediate replacement of thyroid hormones. Administering thyroid hormones intravenously ensures rapid absorption and effectiveness in managing the condition. Choice B, oral administration of hypnotic agents, is incorrect as it does not address the primary issue of thyroid hormone deficiency in myxedema coma. Choice C, intravenous bolus of hydrocortisone, is not the appropriate treatment for myxedema coma as adrenal insufficiency is not the primary concern in this condition. Choice D, subcutaneous administration of vitamin K, is unrelated to the management of myxedema coma and does not address the underlying thyroid hormone deficiency that characterizes this condition.

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