Nursing Elites

1. A nurse is caring for a client who is 1 hour postoperative following a thoracentesis. Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 96%
• B. Tracheal deviation
• C. Pain level of 4 on a scale of 0 to 10
• D. Temperature of 37.4°C (99.3°F)

Correct answer: B

Rationale: Tracheal deviation is the correct finding to report to the provider. It can indicate a pneumothorax, which is a serious complication following a thoracentesis that requires immediate attention. Oxygen saturation of 96% is within the normal range and does not indicate an immediate issue. A pain level of 4 on a scale of 0 to 10 is subjective and may not be related to a serious complication. A temperature of 37.4°C (99.3°F) is slightly elevated but not a priority over tracheal deviation in this context.

2. What is the most appropriate action when a patient experiences a fall in the hospital?

• A. Assess the patient for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct answer is to assess the patient for injuries. When a patient experiences a fall in the hospital, the immediate concern is to check for any injuries that may require urgent care. Calling for help can be done after assessing the patient to ensure appropriate assistance is provided. Documenting the fall is important for the patient's medical record, but it is not the most immediate action needed. Notifying the healthcare provider can come after the initial assessment to update them on the situation.

3. What is the priority nursing intervention for a patient with hyperkalemia?

• A. Administer calcium gluconate
• B. Administer insulin
• C. Administer sodium bicarbonate
• D. Administer a diuretic

Correct answer: A

Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.

4. A nurse is assessing a client who has a urinary tract infection and is receiving ciprofloxacin. Which of the following findings should the nurse report to the provider?

• A. Dry mouth.
• B. Photosensitivity.
• C. Headache.
• D. Urinary retention.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin can cause photosensitivity, making the client more sensitive to sunlight. It is essential for the nurse to report this finding to the provider so that appropriate measures can be taken to prevent skin damage. Dry mouth, headache, and urinary retention are not typically associated with ciprofloxacin use and do not require immediate reporting to the provider in this scenario.

5. 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.

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