Nursing Elites

1. The nurse is caring for a client following a craniotomy. Which finding should the nurse report immediately?

• A. Pupils equal and reactive to light.
• B. Sudden increase in urine output.
• C. Diminished breath sounds bilaterally.
• D. Increase in blood pressure by 20 mmHg.

Correct answer: C

Rationale: The correct answer is C, 'Diminished breath sounds bilaterally.' This finding should be reported immediately as it could indicate a serious complication such as increased intracranial pressure or respiratory compromise. In a post-craniotomy client, changes in breath sounds may be a sign of developing issues that need prompt intervention. Choices A, B, and D are not as critical in the immediate post-craniotomy period. Pupils equal and reactive to light are expected findings, a sudden increase in urine output may require monitoring but not immediate reporting, and a small increase in blood pressure may not be alarming unless it is significantly high or accompanied by other concerning signs.

2. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows has disappeared, and that her eyes are puffy. What follow-up question is best for the nurse to ask?

• A. Have you noticed any changes in your fingernails?
• B. Have you had any changes in weight or energy levels?
• C. Do you have a family history of thyroid problems?
• D. Have you had recent cold intolerance or unusual fatigue?

Correct answer: D

Rationale: The correct answer is D. Cold intolerance, fatigue, and other changes may indicate hypothyroidism, which could explain the hair and eyebrow loss, and puffy eyes. Choices A, B, and C are less relevant in this context and do not directly address the symptoms presented by the client.

3. A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?

• A. Trendelenburg
• B. Supine
• C. Prone
• D. Fowler's

Correct answer: D

Rationale: Fowler's position (head elevated at 45-60 degrees) improves oxygenation by expanding the lungs, making it the best position for clients with dyspnea. Supine or prone positions restrict lung expansion, and Trendelenburg position (head down) can exacerbate breathing difficulties by increasing pressure on the lungs and diaphragm.

4. A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?

• A. International normalized ratio (INR)
• B. Activated partial thromboplastin time (aPTT)
• C. Hemoglobin
• D. Platelet count

Correct answer: B

Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.

5. An older adult client with chronic emphysema is admitted with acute onset of weakness, palpitation, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

• A. Medication compliance over the past few weeks.
• B. Recent sleep patterns and rest.
• C. Recent history of smoking.
• D. Activity level prior to symptom onset.

Correct answer: A

Rationale: The correct answer is A: Medication compliance over the past few weeks. In a client with chronic emphysema experiencing acute symptoms, it is crucial to assess medication compliance as it directly impacts symptom control and disease management. Ensuring the client has been adherent to their prescribed medications can provide insights into potential exacerbating factors or the need for adjustments in the treatment plan. Choices B, C, and D are less critical during the initial assessment compared to medication compliance. Recent sleep patterns and rest (choice B) may be relevant but are secondary to ensuring proper medication management. While smoking history (choice C) is important in chronic lung conditions, the immediate focus should be on the current status of medication use. Activity level prior to symptom onset (choice D) is also pertinent but not as crucial as confirming medication compliance to address the acute symptoms.

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