Nursing Elites

1. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

• A. Chest pain
• B. Muscle spasms
• C. Cool, moist skin
• D. Incisional pain

Correct answer: A

Rationale: In a client who is 30 minutes postoperative following an arterial thrombectomy, chest pain is a critical finding that should be reported immediately. Chest pain can indicate serious complications such as myocardial infarction or pulmonary embolism, which require prompt intervention. Muscle spasms and cool, moist skin are not typical signs of immediate concern following an arterial thrombectomy. Incisional pain is expected postoperatively and may not warrant immediate reporting unless accompanied by other concerning symptoms.

2. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

• A. Acrocyanosis
• B. Vernix caseosa
• C. A respiratory rate of 50/min
• D. Heart rate of 160/min

Correct answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

3. A client has a new ileostomy. Which of the following actions should the nurse take?

• A. Apply a skin barrier around the stoma.
• B. Empty the pouch when it is one-third full.
• C. Change the entire pouching system weekly.
• D. Cleanse the peristomal skin with alcohol.

Correct answer: C

Rationale: Changing the entire pouching system weekly is essential for maintaining skin integrity and preventing infection. Option A is incorrect as applying a skin barrier should be done during the pouch change, not separately. Option B is incorrect as ileostomy pouches should be emptied when they are one-third to one-half full to prevent leakage. Option D is incorrect because cleansing the peristomal skin with alcohol can be too harsh and may cause skin irritation.

4. A nurse is preparing to administer potassium chloride IV to a client who has hypokalemia. Which of the following actions should the nurse take?

• A. Give the medication as a bolus over 10 minutes.
• B. Dilute the medication before administration.
• C. Infuse the medication at a rate of 10 mEq/hr.
• D. Administer the medication undiluted.

Correct answer: C

Rationale: The correct action the nurse should take when administering potassium chloride IV to a client with hypokalemia is to infuse the medication at a rate of 10 mEq/hr. This slow infusion rate is crucial to prevent the development of hyperkalemia, a potentially dangerous condition. Option A is incorrect because giving the medication as a bolus over 10 minutes can lead to adverse effects. Option B is incorrect as potassium chloride does not necessarily need to be diluted before administration in this scenario. Option D is incorrect as administering the medication undiluted can also increase the risk of hyperkalemia.

5. A client reports intimate partner violence to a nurse. What is the nurse's priority action?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Ensure the client has access to legal services.

Correct answer: A

Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.

Similar Questions