Nursing Elites

1. The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Oxygen saturation of 92%.
• C. Temperature of 99°F (37.2°C).
• D. Pain at the surgical site.

Correct answer: C

Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.

2. When caring for a client with a tracheostomy, which action should the nurse take first when performing tracheostomy care?

• A. Remove the inner cannula.
• B. Clean the stoma with normal saline.
• C. Change the tracheostomy ties.
• D. Suction the tracheostomy.

Correct answer: D

Rationale: Suctioning the tracheostomy is the priority action because it ensures a patent airway before proceeding with any other tracheostomy care interventions. This step helps clear secretions and maintain airway patency, which is crucial for the client's respiratory status. Removing the inner cannula, cleaning the stoma, or changing the tracheostomy ties can follow once the airway is clear. Therefore, options A, B, and C are secondary actions compared to suctioning the tracheostomy.

3. The healthcare provider is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?

• A. Serum potassium of 4.0 mEq/L and total calcium of 9 mg/dL.
• B. White blood cell count of 15,000/mm3.
• C. Serum potassium of 5.5 mEq/L and total calcium of 6 mg/dL.
• D. Hemoglobin of 12 g/dL and phosphorus of 2 mg/dL.

Correct answer: C

Rationale: In renal failure and osteodystrophy, there is an alteration in serum electrolyte balance. The correct answer is serum potassium of 5.5 mEq/L and total calcium of 6 mg/dL. Renal failure is associated with hyperkalemia (elevated serum potassium) and hypocalcemia (low total calcium levels). Hyperphosphatemia is also commonly seen in renal failure. Choice A is incorrect as it describes normal levels of serum potassium and total calcium. Choice B is unrelated to the client's condition. Choice D is incorrect as it does not reflect the typical electrolyte imbalances seen in renal failure and osteodystrophy.

4. A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?

• A. ricin
• B. botulism toxin
• C. sulfur mustard
• D. yersinia pestis

Correct answer: B

Rationale: The correct answer is B: botulism toxin. The symptoms described, including symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, are classic manifestations of botulism, which is caused by a toxin produced by Clostridium botulinum. This toxin affects the nervous system, leading to muscle weakness and paralysis. Choice A, ricin, typically presents with gastrointestinal symptoms and organ failure. Choice C, sulfur mustard, causes blistering skin and respiratory issues. Choice D, yersinia pestis, is associated with the plague and presents with fever, chills, weakness, and swollen lymph nodes.

5. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?

• A. Facial weakness and difficulty speaking.
• B. Decreased deep tendon reflexes in the legs.
• C. Inability to move the eyes.
• D. Respiratory distress and cyanosis.

Correct answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.

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