Nursing Elites

1. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

• A. The patient is experiencing laryngeal stridor.
• B. The patient complains of generalized fatigue.
• C. The patient has not had a bowel movement for 4 days.
• D. The patient has numbness and tingling of the lips.

Correct answer: A

Rationale: The correct answer is A - 'The patient is experiencing laryngeal stridor.' Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level to prevent a life-threatening situation. Choices B, C, and D are also symptoms of hypocalcemia, but laryngeal stridor takes precedence due to its potential to quickly progress to a critical condition.

2. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

• A. Skin turgor
• B. Heart sounds
• C. Mental status
• D. Capillary refill

Correct answer: C

Rationale: Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

3. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?

• A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
• B. Only foil balloons will be used for the child's birthday party.
• C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
• D. An epinephrine auto-injector will be on hand to treat allergic reactions.

Correct answer: C

Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.

4. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply).

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: C

Rationale: The correct answer is C: 'Around the nostrils.' Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on, including around the nostrils. Choice A, 'Tops of the ears,' is incorrect as the cannula does not rest on the ears. Choice B, 'Bridge of the nose,' is incorrect because the cannula typically rests under the nose. Choice D, 'Over the cheeks,' is also incorrect as the cannula does not typically rest on the cheeks.

5. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

• A. Avoid using friction when cleaning around the CVAD insertion site.
• B. Use the push-pause method to flush the CVAD after giving medications.
• C. Obtain an order from the healthcare provider to change the CVAD dressing.
• D. Position the patient’s face away from the CVAD during injection cap changes.

Correct answer: B

Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.

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