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. A client with a history of heart failure is admitted with severe dyspnea. Which laboratory result requires immediate intervention?

• A. Blood glucose of 150 mg/dL.
• B. Serum potassium of 3.5 mEq/L.
• C. Serum creatinine of 1.0 mg/dL.
• D. Blood urea nitrogen (BUN) of 20 mg/dL.

Correct answer: C

Rationale: The correct answer is C. A serum creatinine level of 1.0 mg/dL is within the normal range. However, in a client with heart failure and severe dyspnea, fluid retention is a significant concern. An elevated serum creatinine level may indicate impaired kidney function, which can worsen fluid overload. Therefore, immediate intervention is required to prevent further complications. Choices A, B, and D are within normal ranges and not indicative of immediate intervention in this scenario.

3. The nurse obtains a heart rate of 92 and a blood pressure of 110/76 before administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?

• A. Administer the dose as prescribed.
• B. Hold the medication.
• C. Call the healthcare provider.
• D. Repeat the vital signs in 30 minutes.

Correct answer: A

Rationale: The correct action is to administer the dose as prescribed. Verapamil slows sinoatrial nodal automaticity and delays atrioventricular nodal conduction, which helps in slowing the ventricular rate. The heart rate of 92 and blood pressure of 110/76 are within an acceptable range for administering verapamil in a client with atrial flutter. Holding the medication, calling the healthcare provider, or repeating the vital signs in 30 minutes are not necessary based on the vital signs obtained and the action of verapamil in this scenario.

4. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which laboratory result requires immediate intervention?

• A. Amylase of 120 U/L.
• B. Lipase of 150 U/L.
• C. Calcium of 8.5 mg/dL.
• D. Blood glucose of 250 mg/dL.

Correct answer: D

Rationale: The correct answer is D, 'Blood glucose of 250 mg/dL.' In a client with acute pancreatitis, elevated blood glucose levels can indicate poor control of diabetes or stress response from the acute illness. Immediate intervention is necessary to prevent complications like worsening pancreatitis, infections, or other metabolic issues. Choices A and B, 'Amylase of 120 U/L' and 'Lipase of 150 U/L,' are commonly elevated in pancreatitis but do not require immediate intervention unless significantly elevated. Choice C, 'Calcium of 8.5 mg/dL,' is within the normal range and not a priority in this scenario.

5. During a home visit, the nurse finds that an elderly client has multiple expired medications. What should the nurse do first?

• A. instruct the client to dispose of the expired medications
• B. review the client's current medication regimen
• C. contact the client's healthcare provider
• D. educate the client on the dangers of taking expired medications

Correct answer: B

Rationale: The correct first action for the nurse to take when finding multiple expired medications in an elderly client's home is to review the client's current medication regimen. This step is crucial to identify any potential issues, ensure the client is taking the correct medications, and understand why the expired medications were not used. Instructing the client to dispose of the expired medications (Choice A) can come after understanding the current medication situation. Contacting the client's healthcare provider (Choice C) may be necessary but reviewing the medication regimen should be the initial step. Educating the client on the dangers of taking expired medications (Choice D) is important but should be done after addressing the immediate concern of reviewing the current medications.

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