Nursing Elites

1. A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?

• A. Magnesium
• B. Calcium
• C. Chloride
• D. Potassium

Correct answer: C

Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.

2. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?

• A. Stay with the client and observe for airway obstruction
• B. Collect pillows and pad the side rails of the bed
• C. Place an oral airway in the mouth and suction
• D. Announce a cardiac arrest and assist with intubation

Correct answer: A

Rationale: The correct action for the nurse to take next is to stay with the client and observe for airway obstruction. This is crucial as it ensures immediate intervention if there is any airway compromise. Choice B is incorrect as padding the side rails of the bed is not the priority in this situation. Choice C is incorrect because inserting an oral airway and suctioning should only be done if there is evidence of airway obstruction, and it is not the initial step. Choice D is incorrect as announcing a cardiac arrest and assisting with intubation is not the immediate action needed when a client is seizing and losing consciousness.

3. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

• A. Orthostatic hypotension is a common side effect.
• B. Most antipsychotic drugs cause elevated blood pressure.
• C. This provides information on the amount of sodium allowed in the diet.
• D. It will indicate the need to institute anti-parkinsonian drugs.

Correct answer: A

Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.

4. During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?

• A. Breath sounds are auscultated bilaterally
• B. Mist is visible in the T-Piece
• C. Pulse oximetry of 88%
• D. Client is unable to speak

Correct answer: C

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.

5. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to

• A. Wrap the leg with elastic bandages
• B. Apply pressure at the bleeding site
• C. Reinforce the dressing and elevate the leg
• D. Remove the dressings and re-dress the incision

Correct answer: B

Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss. Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding. Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding. Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.

Similar Questions