Nursing Elites

1. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 110/70 mm Hg
• B. Heart rate of 88/min
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: D

Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.

2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider?

• A. Potassium level 4.2 mEq/L
• B. Apical pulse 58/min
• C. Digoxin level 1 ng/ml
• D. Constipation for 2 days

Correct answer: B

Rationale: The correct answer is B. An apical pulse below 60/min indicates bradycardia, a potential sign of digoxin toxicity. The nurse should report this finding to the provider for further evaluation and possible adjustment of the digoxin dose. Choice A, a potassium level of 4.2 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not indicate toxicity. Choice C, a digoxin level of 1 ng/ml, is within the therapeutic range (0.5-2 ng/ml) and is not suggestive of toxicity. Choice D, constipation for 2 days, is not directly related to digoxin administration and would not require an immediate report to the provider.

3. A nurse is planning care for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?

• A. Glomerular filtration rate of 14 mL/minute
• B. BUN 16 mg/dL
• C. Serum magnesium 1.8 mg/dL
• D. Serum phosphorus 4.0 mg/dL

Correct answer: A

Rationale: A glomerular filtration rate of 14 mL/minute indicates severe kidney dysfunction, necessitating hemodialysis. The other options, BUN of 16 mg/dL, serum magnesium of 1.8 mg/dL, and serum phosphorus of 4.0 mg/dL, are within normal ranges and do not serve as indications for hemodialysis.

4. A nurse is teaching a client who is at 10 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make?

• A. This test will confirm whether your baby has a genetic disorder.
• B. Amniocentesis is used to assess your baby's lung maturity.
• C. You should not feel any pain during this procedure.
• D. This test will assess the amount of amniotic fluid around your baby.

Correct answer: A

Rationale: The correct answer is A because amniocentesis is a procedure that confirms genetic disorders by analyzing the amniotic fluid surrounding the baby. Choice B is incorrect because amniocentesis is not used to assess lung maturity. Choice C is incorrect because some discomfort or pain may be felt during the procedure. Choice D is incorrect because amniocentesis does not primarily assess the amount of amniotic fluid around the baby.

5. A healthcare provider is reviewing the laboratory data of a client who is receiving total parenteral nutrition. Which of the following findings should the healthcare provider report?

• A. Serum calcium 8.5 mg/dL
• B. Blood glucose level 120 mg/dL
• C. Serum sodium 138 mEq/L
• D. Serum albumin 3.5 g/dL

Correct answer: D

Rationale: The correct answer is D: Serum albumin 3.5 g/dL. A low serum albumin level indicates protein deficiency, which can be a complication of TPN therapy and requires prompt intervention. The other laboratory findings provided (serum calcium 8.5 mg/dL, blood glucose level 120 mg/dL, and serum sodium 138 mEq/L) are within normal ranges and do not specifically indicate complications related to TPN therapy.

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