Nursing Elites

1. 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.

2. A nurse is reinforcing teaching with a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?

• A. Increase fluid intake by drinking bottled water.
• B. A salad bar is a healthy choice when dining out.
• C. Soft-boiled eggs are an appropriate source of protein.
• D. Eating at buffets is a good choice to increase caloric intake.

Correct answer: A

Rationale: Clients with neutropenia should avoid foods that may be contaminated to prevent infections. Increasing fluid intake is important to stay hydrated, but it's crucial to use safe sources like bottled water to reduce the risk of infection. Choices B, C, and D are not appropriate for a client with neutropenia. Salad bars may contain raw or unwashed produce, soft-boiled eggs may carry a risk of contamination, and buffets may have food items that are not recommended for someone with neutropenia.

3. A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?

• A. Administer insulin as ordered
• B. Encourage the client to drink fluids
• C. Notify the healthcare provider
• D. Recheck the blood glucose level in 30 minutes

Correct answer: A

Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.

4. A nurse is reinforcing teaching about food choice with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?

• A. I will give my child peanut butter and mashed egg whites.
• B. I will give my child rice cereal and crackers.
• C. I will give my child pureed liver and strained pears.
• D. I will give my child applesauce and green peas.

Correct answer: A

Rationale: The correct answer is A because peanut butter and egg whites are not recommended for infants under 12 months due to the risk of choking and allergies. Choices B, C, and D are appropriate food choices for an 8-month-old infant. Rice cereal, crackers, pureed liver, strained pears, applesauce, and green peas are all suitable options for introducing solid foods to infants.

5. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

• A. Assess nail beds for color and refill
• B. Assess for postoperative arrhythmias
• C. Auscultate for pulmonary congestion
• D. Monitor equality of peripheral pulses

Correct answer: B

Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.

Similar Questions