Nursing Elites

1. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator. Which of the following statements demonstrates understanding of the teaching?

• A. I will soak in the tub rather than showering.
• B. I will wear loose clothing around my ICD.
• C. I will stop using my microwave oven at home because of my ICD.
• D. I can hold my cellphone on the same side of my body as the ICD.

Correct answer: B

Rationale: The correct answer is B. Wearing loose clothing around the ICD is essential to avoid putting pressure on the device, which can interfere with its function. Choices A, C, and D are incorrect. Soaking in a tub rather than showering is not relevant to ICD care. Stopping the use of a microwave oven is not necessary with an ICD. Holding a cellphone on the same side as the ICD is not recommended as it can potentially interfere with the device.

2. A nurse is reviewing the medical record of a client who is 24 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min
• B. Serosanguineous drainage in the surgical drain
• C. Temperature 38.6°C (101.5°F)
• D. Urinary output 60 mL/hr

Correct answer: C

Rationale: The correct answer is C. A temperature of 38.6°C (101.5°F) is above the normal range and indicates a fever, which is a concerning finding postoperatively. Fever can be a sign of infection, so the nurse should report this finding to the provider for further evaluation and intervention. Choices A, B, and D are within expected parameters for a client who is 24 hours postoperative following abdominal surgery and do not require immediate reporting. A heart rate of 90/min, serosanguineous drainage in the surgical drain, and a urinary output of 60 mL/hr are all common postoperative findings that do not raise immediate concerns.

3. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?

• A. Hgb 10 g/dL
• B. Platelets 300,000/mm³
• C. WBC count 12,000/mm³
• D. BUN 18 mg/dL

Correct answer: A

Rationale: The correct answer is A: Hgb 10 g/dL. A hemoglobin level of 10 g/dL is below the normal range for a pregnant client, indicating possible anemia, which is crucial to report during pregnancy to prevent complications for both the mother and the baby. Platelets, WBC count, and BUN levels within the listed values are generally within normal ranges for a pregnant individual at 28 weeks of gestation. Platelets play a role in blood clotting, WBC count helps in fighting infections, and BUN measures kidney function, all of which are typically expected to be within normal limits during pregnancy.

4. A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?

• A. Client placed in restraints due to aggressive behavior
• B. A new client with a history of 4.5 kg weight loss in the past two months
• C. Client receiving PRN dose of haloperidol 2 hours ago for anxiety
• D. Client receiving first ECT treatment today

Correct answer: A

Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.

5. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

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