Nursing Elites

1. The client is recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?

• A. The client lies flat in the supine position for 12 hours
• B. The client continues oral fluids restriction while on bed rest
• C. The client’s family changed the dressing on return to the room
• D. The family activates the patient-controlled analgesia pump

Correct answer: A

Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy helps prevent bleeding, which is crucial for the client's recovery. This position aids in applying pressure to the biopsy site, reducing the risk of bleeding and ensuring optimal healing. Choices B, C, and D do not directly relate to compliance with client teaching after a renal biopsy. Continuing oral fluids restriction, changing the dressing, or activating a patient-controlled analgesia pump are not specific instructions aimed at promoting recovery and preventing complications post renal biopsy.

2. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

• A. Deep tendon reflexes
• B. Arterial blood gases
• C. Skin turgor
• D. Capillary refill time

Correct answer: A

Rationale: Corrected Rationale: When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Assessing arterial blood gases, skin turgor, or capillary refill time is not directly related to the administration of magnesium sulfate in this scenario.

3. A patient is prescribed an oral anticoagulant. What should the nurse monitor for?

• A. Elevated blood glucose
• B. Decreased blood pressure
• C. Signs of bleeding
• D. Increased appetite

Correct answer: C

Rationale: Correct! When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants are medications that prevent blood clot formation but can increase the risk of bleeding. Monitoring for signs such as easy bruising, blood in urine or stool, and prolonged bleeding from minor cuts is essential. Choices A, B, and D are incorrect because oral anticoagulants do not typically affect blood glucose levels, blood pressure, or appetite.

4. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?

• A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes
• B. The nurse noted unilateral breast enlargement
• C. The child’s scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass
• D. The child’s scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct answer: D

Rationale: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.

5. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?

• A. Ensure the scene is safe, assess responsiveness, call for help, begin chest compressions, give two rescue breaths
• B. Give two rescue breaths
• C. Look, listen, and feel for breathing
• D. Begin chest compressions

Correct answer: A

Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.

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