Nursing Elites

1. Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete immediately?

• A. Presence of the Chvostek’s sign
• B. Abnormal serum potassium level
• C. Decreased thyroid hormone level
• D. Bleeding on the patient’s dressing

Correct answer: A

Rationale: The correct assessment the nurse should complete immediately is checking for the presence of the Chvostek’s sign. The patient's complaint of tingling around the mouth is indicative of hypocalcemia, which can result from parathyroid injury/removal during thyroidectomy. The Chvostek’s sign is a clinical indication of hypocalcemia, where facial muscle twitching occurs when the facial nerve is tapped. Assessing serum potassium levels (choice B) is not the priority in this situation. While thyroid hormone levels (choice C) play a role in overall health, they do not directly relate to the patient’s current symptoms. Checking for bleeding on the dressing (choice D) is important but not the immediate priority when addressing potential hypocalcemia.

2. A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

• A. The patient’s radial pulse is 105 beats/minute.
• B. There is sediment and blood in the patient’s urine.
• C. The blood pressure increases from 120/80 to 142/94.
• D. There are crackles audible throughout both lung fields.

Correct answer: D

Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the presence of sediment and blood in the urine should also be reported, but they are not as immediately dangerous as the presence of fluid in the alveoli, which compromises gas exchange and can lead to respiratory failure.

3. When assessing a male client, the nurse finds that he is fatigued, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The correct answer is D, Hypokalemia. Generalized weakness, muscle weakness, leg cramps, and cardiac dysrhythmias are manifestations of hypokalemia. Checking the potassium level is essential in this case. Hypocalcemia typically presents with facial muscle spasms, not the symptoms mentioned. Hypermagnesemia does not typically cause the symptoms described. It's important to note that orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are more commonly associated with hyperkalemia, not hypokalemia.

4. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

• A. red and edematous stoma appearance
• B. liquid brown drainage from stoma
• C. stoma output of 40ml in the last hour
• D. mucous strings floating in the drainage

Correct answer: C

Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.

5. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

• A. Blood pressure is 90/40 mm Hg.
• B. Urine output is 30 mL over the last hour.
• C. Oral fluid intake is 100 mL over the last 8 hours.
• D. There is prolonged skin tenting over the sternum.

Correct answer: A

Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.

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