Nursing Elites

1. What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?

• A. Maintain adequate hydration
• B. Assist the client to turn, deep breathe, and cough
• C. Ambulate the client within 12 hours
• D. Splint the incision

Correct answer: B

Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.

2. The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

• A. Respiratory rate of 16 breaths per minute
• B. Blood pressure of 120/80 mm Hg
• C. Temperature of 99.5 degrees Fahrenheit
• D. Heart rate of 80 beats per minute

Correct answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

3. A nurse is reinforcing teaching with a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select one that doesn't apply).

• A. Cottage cheese
• B. Milkshake
• C. Tuna fish
• D. Strawberries and bananas

Correct answer: D

Rationale: The correct answer is D - Strawberries and bananas. Cottage cheese, milkshakes, and tuna fish are high in protein and calories, making them beneficial in preventing protein-energy malnutrition. However, strawberries and bananas are not as protein or calorie-dense compared to the other options, so they are not as effective in preventing malnutrition.

4. For a client with chronic kidney disease having a hemoglobin level of 8.0 g/dL, which intervention should the nurse perform first?

• A. Administer erythropoietin as ordered
• B. Monitor the client's blood pressure
• C. Monitor the client's oxygen saturation level
• D. Assess the client for signs of fatigue

Correct answer: A

Rationale: Administering erythropoietin is the priority intervention for a client with chronic kidney disease and a low hemoglobin level. Erythropoietin stimulates red blood cell production, helping to manage anemia in these clients. Monitoring blood pressure, oxygen saturation level, and assessing for signs of fatigue are important aspects of care but addressing the anemia by administering erythropoietin takes precedence to improve oxygen-carrying capacity and overall well-being.

5. A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?

• A. Magnesium
• B. Calcium
• C. Chloride
• D. Potassium

Correct answer: C

Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.

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