Nursing Elites

1. After a thyroidectomy, which vital sign is the most important for the nurse to monitor closely?

• A. Monitor respiratory rate and rhythm.
• B. Assess for signs of hypocalcemia.
• C. Monitor for elevated body temperature.
• D. Check blood pressure every 30 minutes.

Correct answer: B

Rationale: The correct answer is B: Assess for signs of hypocalcemia. After a thyroidectomy, monitoring for hypocalcemia is crucial because damage to the parathyroid glands during surgery can result in low calcium levels, which may cause life-threatening complications. Monitoring respiratory rate and rhythm (choice A) is important but not the most critical in this situation. Monitoring for elevated body temperature (choice C) is less of a priority post-thyroidectomy. Checking blood pressure every 30 minutes (choice D) is not as vital as monitoring for hypocalcemia in this context.

2. A male client admitted for schizophrenia is noted to be diaphoretic and pacing the hallway. What is the most important intervention?

• A. Take the client's temperature and blood pressure.
• B. Encourage the client to rest.
• C. Plan an activity involving physical exercise.
• D. Carefully observe the client throughout the shift.

Correct answer: D

Rationale: In this scenario, the most important intervention for a male client with schizophrenia who is diaphoretic and pacing the hallway is to carefully observe the client throughout the shift. Diaphoresis and pacing can be indicators of agitation or distress in clients with schizophrenia. Careful observation is crucial to monitor the client's safety, assess for any potential escalation of symptoms, and provide timely intervention if needed. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for safety and observation. Encouraging the client to rest (Choice B) may not be effective if the client is agitated. Planning an activity involving physical exercise (Choice C) could potentially exacerbate the situation rather than addressing the immediate need for observation and safety.

3. A client is admitted with pneumonia and is started on antibiotics. After 3 days, the client reports difficulty breathing and a rash. What is the nurse's first action?

• A. Administer epinephrine
• B. Discontinue the antibiotic
• C. Assess the client's oxygen saturation
• D. Call the healthcare provider

Correct answer: B

Rationale: The client's difficulty breathing and rash suggest a possible allergic reaction to the antibiotic. The first action the nurse should take is to discontinue the antibiotic to prevent further exposure. Administering epinephrine should only be done in severe cases of anaphylaxis, which is not indicated solely by difficulty breathing and rash. While assessing the client's oxygen saturation is important, discontinuing the potential allergen takes precedence. Contacting the healthcare provider should be done after discontinuing the antibiotic and assessing the client to report the situation and seek further guidance.

4. A client is scheduled for a colonoscopy and has been prescribed a bowel preparation. What is the most important instruction for the nurse to provide?

• A. Eat a low-fiber diet the day before the procedure
• B. Drink clear liquids 24 hours before the procedure
• C. Take the entire bowel preparation as directed
• D. Avoid all solid foods 12 hours before the procedure

Correct answer: C

Rationale: The most important instruction for the nurse to provide to a client scheduled for a colonoscopy and prescribed a bowel preparation is to take the entire bowel preparation as directed. Completing the entire bowel preparation as prescribed is crucial to ensure the colon is properly cleansed for the colonoscopy. Incomplete bowel prep can interfere with the visualization of the colon, leading to inaccurate results. Choices A, B, and D are important but not as crucial as ensuring the complete intake of the bowel preparation for an effective procedure.

5. Which of these findings would the nurse more closely associate with anemia in a 10-month-old infant?

• A. Hemoglobin level of 12 g/dL
• B. Pale mucosa of the eyelids and lips
• C. Hypoactivity
• D. A heart rate between 140 to 160

Correct answer: B

Rationale: The correct answer is B. Pale mucous membranes, such as those of the eyelids and lips, are a classic sign of anemia in infants. Anemia leads to decreased oxygen-carrying capacity, resulting in tissue hypoxia, which can manifest as pale mucosa. Choice A, a hemoglobin level of 12 g/dL, is within the normal range for a 10-month-old infant and would not necessarily indicate anemia. Choice C, hypoactivity, is a non-specific finding and can be present in various conditions, not specifically anemia. Choice D, a heart rate between 140 to 160, is within the normal range for an infant and is not a specific finding associated with anemia.

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