Nursing Elites

1. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

• A. Increased hoarseness
• B. Serum calcium level of 8.0 mg/dL
• C. Respiratory rate of 18/min
• D. Urinary output of 60 mL in 2 hours

Correct answer: B

Rationale: The correct answer is B: 'Serum calcium level of 8.0 mg/dL.' A low serum calcium level indicates hypocalcemia, which is a potential complication of thyroidectomy that can lead to life-threatening consequences, such as tetany or laryngospasm. Therefore, it is crucial for the nurse to report this finding promptly to the provider for timely intervention. Choices A, C, and D are important assessments following a thyroidectomy but are not as critical as detecting and addressing hypocalcemia, which can have serious implications for the client's health.

2. A nurse is preparing to teach a client about the use of a peak flow meter. Which of the following instructions should the nurse include?

• A. Place the mouthpiece in your mouth and blow out as quickly as you can.
• B. Exhale slowly into the mouthpiece over 5 seconds.
• C. Take a slow deep breath before blowing into the mouthpiece.
• D. Blow into the mouthpiece at a steady rate for 3 seconds.

Correct answer: A

Rationale: The correct instruction for using a peak flow meter is to place the mouthpiece in your mouth and blow out as quickly as you can. This action helps measure the peak expiratory flow of the client. Choice B is incorrect because exhaling slowly does not provide an accurate peak flow reading. Choice C is incorrect as taking a slow deep breath before blowing interferes with obtaining an accurate measurement. Choice D is incorrect as blowing at a steady rate for 3 seconds may not reflect the peak expiratory flow accurately.

3. A nurse is planning to teach a group of clients about preventing low back pain. Which of the following information should the nurse include?

• A. Wear low-heeled shoes.
• B. Elevate the legs while sitting.
• C. Engage in prolonged sitting to rest the back muscles.
• D. Sleep on a soft mattress to prevent strain on the back.

Correct answer: A

Rationale: The correct answer is A: 'Wear low-heeled shoes.' Wearing low-heeled shoes helps prevent back strain by promoting proper posture. High heels can cause an imbalance in the body's alignment, leading to increased stress on the lower back. Choices B, C, and D are incorrect. Elevating the legs while sitting can help with circulation but does not directly prevent low back pain. Engaging in prolonged sitting can actually contribute to low back pain due to decreased muscle activity and increased pressure on the spine. Sleeping on a soft mattress may not provide adequate support for the back, potentially worsening back pain instead of preventing it.

4. A nurse is assessing a client who is receiving a continuous heparin infusion. Which of the following findings should the nurse report to the provider?

• A. Platelet count of 200,000/mm³
• B. aPTT of 50 seconds
• C. Hemoglobin of 14 g/dL
• D. INR of 1.0

Correct answer: D

Rationale: The correct answer is D because an INR of 1.0 is below the therapeutic range for clients receiving heparin, indicating a potential need for dosage adjustment. Platelet count (choice A) within normal range, aPTT (choice B) within therapeutic range, and hemoglobin level (choice C) are not directly related to the monitoring of heparin therapy and would not require immediate reporting to the provider.

5. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

• A. Position the client supine.
• B. Prepare an IV bolus of dextrose 5% in water.
• C. Administer methylergonovine IM.
• D. Administer calcium gluconate IV.

Correct answer: D

Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.

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