Nursing Elites

1. What is the best initial action when a patient presents with confusion?

• A. Administer IV fluids
• B. Perform a neurological assessment
• C. Administer electrolytes
• D. Prepare for a CT scan

Correct answer: B

Rationale: When a patient presents with confusion, the best initial action is to perform a neurological assessment. This assessment helps in identifying potential causes of confusion such as neurological issues, infections, metabolic abnormalities, or medication side effects. Administering IV fluids (Choice A) may be necessary based on assessment findings, but it is not the first step. Administering electrolytes (Choice C) would also depend on the assessment results. Preparing for a CT scan (Choice D) may be indicated later in the diagnostic process but is not the initial action when a patient presents with confusion.

2. A nurse is caring for a client who is 2 hours postoperative following a cholecystectomy. Which of the following actions should the nurse take to prevent postoperative complications?

• A. Instruct the client to perform deep breathing and coughing exercises.
• B. Have the client wear sequential compression devices (SCDs).
• C. Place the client in a supine position with the head of the bed flat.
• D. Encourage the client to ambulate every 2 hours.

Correct answer: B

Rationale: The correct answer is B: Have the client wear sequential compression devices (SCDs). Following a cholecystectomy, the client is at risk for venous thromboembolism (VTE) due to reduced mobility and surgical stress. SCDs help prevent VTE by promoting venous return and reducing the risk of blood clots. Choices A, C, and D are incorrect. While deep breathing and coughing exercises are essential postoperatively, SCDs take precedence in preventing VTE. Placing the client in a supine position with the head of the bed flat can increase the risk of respiratory complications. Encouraging ambulation is important, but SCDs are a higher priority in this situation to prevent VTE.

3. A nurse is caring for a client who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

• A. WBC 4,500/mm3
• B. Hemoglobin 12 g/dL
• C. Platelet count 250,000/mm3
• D. Platelet count 100,000/mm3

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm3 is lower than the normal range, indicating thrombocytopenia, which is concerning in clients receiving chemotherapy. Thrombocytopenia can lead to an increased risk of bleeding and bruising. Choices A, B, and C fall within the normal range and would not be a cause for concern in a client receiving chemotherapy.

4. Which of the following is the most concerning electrolyte imbalance for a patient on furosemide?

• A. Hypokalemia
• B. Hyperkalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is Hypokalemia. Furosemide, a loop diuretic, can lead to potassium depletion in the body, causing hypokalemia. This is a significant concern as low potassium levels can result in cardiac arrhythmias and other serious complications. Hyperkalemia (Choice B) is unlikely to occur as a result of furosemide use. Hyponatremia (Choice C) is more commonly associated with thiazide diuretics. Hypercalcemia (Choice D) is not typically linked to furosemide use.

5. A client with a new prescription for levothyroxine is receiving discharge teaching. Which of the following client statements indicates an understanding of the teaching?

• A. I should take this medication with food to prevent nausea.
• B. I will take this medication every morning before breakfast.
• C. I will stop taking this medication if I experience chest pain.
• D. I will take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Levothyroxine should be taken every morning before breakfast to enhance absorption and maintain consistent thyroid hormone levels. Option A is incorrect because levothyroxine should be taken on an empty stomach. Option C is incorrect because chest pain is not a common side effect of levothyroxine and stopping the medication abruptly can be harmful. Option D is incorrect because taking levothyroxine at bedtime may result in decreased absorption due to interactions with food and other medications.

Similar Questions