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. Which signs/symptoms would be considered classical signs of meningeal irritation?

• A. Positive Kernig sign, diarrhea, and headache
• B. Negative Brudzinski sign, positive Kernig sign, and irritability
• C. Positive Brudzinski sign, positive Kernig sign, and photophobia
• D. Negative Kernig sign, vomiting, and fever

Correct answer: C

Rationale: The correct answer is C: Positive Brudzinski sign, positive Kernig sign, and photophobia are considered classical signs of meningeal irritation. The Kernig sign is positive when the leg is extended at the knee and then raised, resulting in pain and resistance. The Brudzinski sign is positive when flexing the neck causes flexion of the hips and knees due to meningeal irritation. Photophobia, or sensitivity to light, is a common symptom due to meningeal inflammation. Choices A, B, and D are incorrect because they do not include the classic signs associated with meningeal irritation.

3. A client with hyperthyroidism is prescribed methimazole. Which adverse effect should the nurse monitor for?

• A. Agranulocytosis
• B. Hypoglycemia
• C. Bradycardia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is Agranulocytosis. Methimazole, used to treat hyperthyroidism, can lead to agranulocytosis, a severe decrease in white blood cells. This condition increases the risk of infections and requires immediate medical attention. Hypoglycemia (choice B) is not a common adverse effect of methimazole. Bradycardia (choice C) is unlikely as methimazole tends to have minimal effects on heart rate. Hypercalcemia (choice D) is not associated with methimazole use.

4. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

• A. Daily weight
• B. Vital signs
• C. Level of consciousness
• D. Bowel sounds

Correct answer: A

Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.

5. A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects. Which type of hearing loss should the nurse suspect?

• A. Conductive
• B. Sensorineural
• C. Mixed
• D. Central

Correct answer: B

Rationale: The correct answer is B: Sensorineural. Ototoxic medications can lead to sensorineural hearing loss by affecting the inner ear or auditory nerve. Conductive hearing loss is related to issues in the middle or outer ear, not typically caused by ototoxic medications. Mixed hearing loss is a combination of conductive and sensorineural components. Central hearing loss is related to the central nervous system, not commonly caused by ototoxic medications. Therefore, in this case, the nurse should suspect sensorineural hearing loss.

Similar Questions