Nursing Elites

1. The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?

• A. Heart rate of 88 beats per minute
• B. Blood pressure of 100/60
• C. Oxygen saturation of 94%
• D. Respiratory rate of 16

Correct answer: C

Rationale: The correct answer is C. Oxygen saturation levels below 95% indicate hypoxia and require immediate intervention. A heart rate of 88 beats per minute, a blood pressure of 100/60, and a respiratory rate of 16 are within normal ranges and do not require immediate intervention. Oxygen saturation is a critical parameter reflecting the client's oxygenation status.

2. What assessment is most important for the nurse to perform for a client with dehydration receiving IV fluids?

• A. Monitor the client’s electrolyte levels.
• B. Check the client’s urine output hourly.
• C. Assess the client’s skin turgor regularly.
• D. Monitor the client’s blood pressure every 15 minutes.

Correct answer: A

Rationale: The correct answer is to monitor the client’s electrolyte levels. When a client is receiving IV fluids for dehydration, it is crucial to assess their electrolyte levels regularly. Dehydration can lead to imbalances in electrolytes, especially sodium and potassium, which are essential for maintaining fluid balance and proper organ function. Checking urine output (Choice B) is important but not as critical as monitoring electrolyte levels. Assessing skin turgor (Choice C) is an indirect method of assessing dehydration but does not provide specific information about electrolyte imbalances. Monitoring blood pressure (Choice D) is important but not the most critical assessment in this scenario as electrolyte imbalances can have a more direct impact on the client's condition.

3. The nurse is caring for a 69-year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Test blood sugar every 2 hours using Accu-Chek
• B. Review signs of hyperglycemia with the family and client
• C. Administer insulin if the blood sugar is elevated
• D. Measure the client's urine output

Correct answer: D

Rationale: The correct answer is D because measuring urine output is a task that falls within the UAP's scope of practice and does not require clinical decision-making. Choice A is incorrect because testing blood sugar using Accu-Chek involves interpreting results and possible adjustments, which require a licensed healthcare provider. Choice B is incorrect as discussing signs of hyperglycemia involves education and interpretation that should be done by a nurse. Choice C is incorrect since administering insulin is a high-risk task that necessitates precise dosing and monitoring, thus should not be delegated to UAP.

4. While palpating the gallbladder of a mildly obese client, what finding does the nurse expect if the gallbladder is inflamed?

• A. Severe tenderness and guarding
• B. Slight discomfort upon palpation
• C. A sensation of fullness
• D. No symptoms unless the gallbladder is extremely inflamed

Correct answer: A

Rationale: Correct. If the gallbladder is inflamed, the nurse would expect to find severe tenderness and guarding, which are typical signs of acute cholecystitis. This indicates an inflammatory process in the gallbladder. Choices B, C, and D are incorrect because slight discomfort, a sensation of fullness, or no symptoms unless extremely inflamed are not typical findings associated with gallbladder inflammation.

5. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?

• A. Increase the client's sedative dose
• B. Encourage the client to express her feelings and provide emotional support
• C. Initiate breathing techniques to manage anxiety
• D. Administer anxiolytic medication to calm the client

Correct answer: B

Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.

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