Nursing Elites

1. The nurse is providing postoperative care for a client who had a thyroidectomy. Which assessment finding requires immediate intervention?

• A. Hoarseness and weak voice
• B. Calcium level of 8.0 mg/dL (2.0 mmol/L)
• C. Heart rate of 110 beats per minute
• D. Difficulty swallowing

Correct answer: D

Rationale: Difficulty swallowing can indicate swelling or hematoma formation, which may compromise the airway and requires immediate intervention. Hoarseness and a weak voice are expected post-thyroidectomy due to manipulation of the laryngeal nerves but do not require immediate intervention. A calcium level of 8.0 mg/dL is within the normal range (8.5-10.5 mg/dL) and may not require immediate intervention. A heart rate of 110 beats per minute may be elevated due to stress or pain postoperatively, but it does not indicate an immediate threat to the airway.

2. While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values?

• A. Neutrophil count.
• B. Hematocrit.
• C. Blood pH.
• D. Serum potassium and sodium.

Correct answer: A

Rationale: The correct answer is A: Neutrophil count. Neutrophil count helps assess for infection, which is indicated by the redness, tenderness, and swelling of the wound. Elevated neutrophil count is a common sign of bacterial infection. Hematocrit (choice B) measures the proportion of blood volume that is occupied by red blood cells and is not directly related to wound infection. Blood pH (choice C) and serum potassium and sodium (choice D) are important for assessing acid-base balance and electrolyte levels but are not the primary indicators of wound infection.

3. A client with asthma is prescribed a metered-dose inhaler (MDI) with albuterol. Which instruction is essential for the nurse to provide?

• A. Use the inhaler only before bedtime
• B. Shake the inhaler well before use
• C. Exhale fully before inhaling the medication
• D. Take two puffs every hour

Correct answer: B

Rationale: The correct answer is to 'Shake the inhaler well before use.' This instruction is crucial as shaking the inhaler ensures the proper mixing of the medication, which is essential for its effective delivery. Option A is incorrect because using the inhaler only before bedtime may not provide adequate relief during the day. Option C is incorrect as exhaling fully is a good practice but not the most essential instruction. Option D is incorrect as taking two puffs every hour may exceed the recommended dosage and lead to adverse effects.

4. The nurse is triaging clients who have been injured during a tornado. Which client requires immediate action?

• A. A young male with a minor laceration on his forearm.
• B. An elderly woman with a dislocated shoulder who is calm.
• C. A middle-aged female with a broken humerus who is unable to follow commands and is crying.
• D. A teenager with abrasions and a bruised knee.

Correct answer: C

Rationale: The middle-aged female with a broken humerus who is unable to follow commands and is crying requires immediate action. These symptoms indicate a possible head injury or severe emotional distress that need urgent attention. Choice A is not as urgent since a minor laceration can be addressed after more critical cases. Choice B, although having a dislocated shoulder, is stable, as the client is calm. Choice D presents with minor injuries that can wait while more critical cases are addressed.

5. The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?

• A. Check the BP every five minutes for one hour.
• B. Raise the HOB 60 to 90 degrees.
• C. Ask the client to cough and deep breathe.
• D. Take the client’s temperature using another method.

Correct answer: D

Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (Choice A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (Choice B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (Choice C) is a general intervention that may not directly address the specific concern of the low temperature reading.

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