Nursing Elites

1. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure?

• A. Light yellow coloring of the client's skin and eyes.
• B. The client's blood pressure reading of 184/88 mm Hg.
• C. The client vomits 20 ml of clear yellowish fluid.
• D. The IV insertion site is red, swollen, and leaking IV fluid.

Correct answer: B

Rationale: The correct answer is B. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risks associated with surgery. The healthcare provider should be notified to manage the blood pressure before proceeding with the scheduled procedure. Choices A, C, and D are incorrect: A, light yellow coloring of the client's skin and eyes may indicate jaundice, but it is not an immediate concern for the scheduled procedure; C, vomiting clear yellowish fluid may suggest bile reflux, but it does not pose an immediate risk to the procedure; D, red, swollen, and leaking IV insertion site indicates a local complication that requires intervention but does not have a direct impact on proceeding with the scheduled surgery.

2. A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?

• A. Elevated temperature
• B. Generalized weakness
• C. Diminished lung sounds
• D. Pain when swallowing

Correct answer: D

Rationale: In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.

3. When interacting with the parents of a SIDS infant, the nurse should attempt to assist the parents with:

• A. Encouraging the parents to have another baby.
• B. Encouraging the parents to remain stoic.
• C. Allaying feelings of guilt and blame.
• D. Learning how the event could have been prevented.

Correct answer: C

Rationale: The correct answer is C: Allaying feelings of guilt and blame. When parents experience the loss of a SIDS infant, they often struggle with intense feelings of guilt and self-blame. The nurse's role is to provide emotional support and help alleviate these feelings. Choices A and B are incorrect as encouraging the parents to have another baby or to remain stoic is not appropriate or helpful in this situation. Choice D is also incorrect because focusing on how the event could have been prevented may exacerbate feelings of guilt and is not the immediate priority in supporting grieving parents.

4. A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity
• B. Fluid volume deficit
• C. Imbalanced nutrition: less than body requirements
• D. Activity intolerance

Correct answer: B

Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.

5. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion from the nurse is the most appropriate?

• A. Enrolling her in a health club
• B. Taking her to the mall in a wheelchair
• C. Purchasing clothes to disguise the brace
• D. Spending a majority of their time with her

Correct answer: C

Rationale: The most appropriate suggestion from the nurse is to recommend purchasing clothes to disguise the brace. Adolescents with scoliosis often have body image concerns and wish to fit in with their peers. By providing clothes that help conceal the brace, the family can support the teenage girl's emotional well-being. Choices A, B, and D do not directly address the adolescent's concerns about body image and fitting in, making them less appropriate in this situation.

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