Nursing Elites

1. After successful resuscitation, a client is given propranolol and transferred to the Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse?

• A. Dark amber urine draining via an indwelling catheter at a rate of 40 ml per hour
• B. Serum calcium of 9.0 mg/dl (2.2 mmol/L SI) and magnesium of 1.8 mg/dl or Eq/L (0.74 mmol/L SI)
• C. Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62
• D. Respiratory rate of 10 breaths per minute

Correct answer: D

Rationale: The correct answer is D. A low respiratory rate of 10 breaths per minute is indicative of possible magnesium toxicity, which can be a serious condition requiring immediate intervention. It is a critical finding that needs prompt attention to prevent further complications. The other options are not as urgent: A - dark amber urine may indicate dehydration but does not require immediate intervention, B - serum calcium and magnesium levels are within normal limits, C - sinus rhythm and blood pressure values are also within normal range and do not require immediate action.

2. A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include in the discharge teaching?

• A. Engage in physical exercise before eating to help decrease cholesterol levels.
• B. Avoid walking briskly in cold weather to prevent a decrease in cardiac output.
• C. Keep nitroglycerin in a light-colored plastic bottle and readily available.
• D. Avoid all isometric exercises, but walk regularly.

Correct answer: C

Rationale: The correct answer is to keep nitroglycerin in a light-colored container and readily available. Nitroglycerin should be protected from light to maintain its effectiveness. Option A is incorrect because physical exercise immediately before eating can trigger angina. Option B is incorrect as cold weather can exacerbate angina symptoms. Option D is incorrect as isometric exercises can increase the workload on the heart, which is not recommended for individuals with angina.

3. An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during post-procedure care in the outpatient surgical unit?

• A. Apply bilateral eye patches while sleeping
• B. Use a whiteboard to communicate with the client
• C. Arrange food on the plate in a clockwise order
• D. Verbally identify oneself when entering the room

Correct answer: A

Rationale: The correct intervention is to apply bilateral eye patches while sleeping. This measure helps protect the eyes and support healing following photocoagulation for macular degeneration. Choice B is incorrect as using a whiteboard is not directly related to post-procedure care for this intervention. Choice C is incorrect as arranging food on the plate in a clockwise order is not relevant to the post-procedure care of photocoagulation. Choice D is incorrect as verbally identifying oneself when entering the room is important for communication but not specific to the post-procedure care in this scenario.

4. The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

• A. Insert an indwelling urinary catheter
• B. Monitor for the appearance of an incisional hernia
• C. Instruct the client to eat small frequent meals
• D. Measure hourly urinary output

Correct answer: D

Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.

5. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks what happened. She doesn’t respond. What should the nurse do next?

• A. Find supplies to put a dressing on the client’s wrists
• B. Take the client to a room for supervision by staff
• C. Call the healthcare provider to report the client’s behavior
• D. Go find a staff member to stay in the room with the client

Correct answer: B

Rationale: In this situation, the nurse's priority is to ensure the safety and supervision of the client. Moving the client to a room for direct supervision by staff is crucial to prevent further harm and provide immediate support. While cleaning and assessing the client's wrists are important, ensuring ongoing supervision is vital in this scenario. Calling the healthcare provider to report the behavior may be necessary but is not the immediate action required. Finding supplies to dress the client's wrists is important but not as urgent as ensuring constant supervision by staff.

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