Nursing Elites

1. A healthcare provider is reviewing the medical record of a client who has Cushing's disease. Which of the following findings should the healthcare provider expect?

• A. Decreased serum glucose level
• B. Increased lymphocyte count
• C. Increased serum potassium level
• D. Decreased serum sodium level

Correct answer: C

Rationale: In Cushing's disease, there is increased cortisol production, which can lead to various metabolic disturbances. One of the common findings is an increased serum potassium level. The other options are incorrect because Cushing's disease typically causes hyperglycemia, not decreased serum glucose levels (A), lymphocytopenia, not increased lymphocyte count (B), and hyponatremia, not decreased serum sodium level (D).

2. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm of the edge of the sterile field.
• D. Set up the sterile field 5 cm below waist level.

Correct answer: B

Rationale: When setting up a sterile field for a dressing change, the nurse should open the outermost flap of the sterile kit away from the body. This action helps maintain the sterility of the field by minimizing the risk of contamination. Option A is incorrect because the cap from the solution should be placed sterile side down to prevent contamination. Option C is incorrect because the sterile dressing should be placed at least 1.25 cm away from the edge of the sterile field to maintain its sterility. Option D is incorrect because the sterile field should be set up above waist level to prevent potential contamination from reaching the field.

3. What is the most important assessment for a patient post-surgery?

• A. Monitor vital signs
• B. Check surgical site for bleeding
• C. Check for abnormal breath sounds
• D. Check skin color

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs provide crucial information about a patient's physiological status, helping detect early signs of complications such as shock, bleeding, or infection. Checking the surgical site for bleeding is important but falls secondary to monitoring vital signs, which give a broader overview of the patient's condition. Checking for abnormal breath sounds and skin color are also important assessments, but they are not as immediate and general as monitoring vital signs in detecting various post-surgical complications.

4. A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this situation is whether they have any active lesions due to the history of herpes simplex virus. This is crucial to assess the risk of transmission to the newborn during labor. Option A is not the priority in this case as the focus is on the client's history of herpes simplex virus. Option B is important but does not directly relate to the risk of herpes simplex virus transmission. Option D is unrelated to the client's condition and the current situation.

5. A client receiving morphine via patient-controlled analgesia (PCA) should have naloxone administered if their respiratory rate is below 10/min. What action should the nurse take?

• A. Monitor the client's blood pressure every 4 hours.
• B. Ask the client to rate their pain every 2 hours.
• C. Administer naloxone if the client's respiratory rate is below 10/min.
• D. Evaluate the client's use of the PCA every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to administer naloxone if the client's respiratory rate falls below 10/min. Naloxone is used to reverse opioid-induced respiratory depression, which is a life-threatening situation. Monitoring the client's blood pressure every 4 hours (Choice A) is not the priority in this scenario as respiratory depression requires immediate attention. Asking the client to rate their pain every 2 hours (Choice B) is important for pain management but addressing respiratory depression takes precedence. Evaluating the client's use of the PCA every 4 hours (Choice D) is a routine nursing intervention but does not directly address the urgent need to reverse respiratory depression in this case.

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