Nursing Elites

1. What is the primary nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Monitor vital signs
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

2. Which electrolyte imbalance is most common in patients receiving furosemide?

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

Correct answer: A

Rationale: The correct answer is A, Hypokalemia. Furosemide, a loop diuretic, commonly leads to potassium loss in the urine, causing hypokalemia. This electrolyte imbalance should be closely monitored in patients taking furosemide. Choices B, C, and D are incorrect because hypercalcemia, hyponatremia, and hyperkalemia are not typically associated with furosemide use.

3. A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings indicates the client is developing diabetes insipidus?

• A. Polyuria
• B. Hypertension
• C. Bradycardia
• D. Hyperglycemia

Correct answer: A

Rationale: Polyuria is the correct finding indicating the client is developing diabetes insipidus. Diabetes insipidus is characterized by the excretion of large volumes of diluted urine due to a deficiency in antidiuretic hormone. This results in increased urine output (polyuria) despite adequate fluid intake. Hypertension (choice B) is not typically associated with diabetes insipidus but can be seen in other conditions. Bradycardia (choice C) and hyperglycemia (choice D) are also not typical findings of diabetes insipidus.

4. A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the unit due to a staffing shortage. Which of the following clients should the nurse delegate to the LPN?

• A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
• B. A client who sustained a concussion and has unequal pupils.
• C. A client who is postoperative following a bowel resection with an NG tube.
• D. A client who fractured his femur yesterday and is experiencing shortness of breath.

Correct answer: C

Rationale: The correct answer is C because a client who is postoperative following a bowel resection with an NG tube can be delegated to an LPN as this involves routine postoperative care. Option A involves administering packed RBCs which requires assessment and monitoring for potential adverse reactions, not suitable for delegation to an LPN. Option B requires neurological assessment and close monitoring due to the concussion, which is beyond the scope of an LPN. Option D involves a client with a recent fracture and shortness of breath, which requires urgent assessment and intervention beyond the LPN's scope of practice.

5. A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. Bradycardia.
• C. Jugular vein distention.
• D. Dependent edema.

Correct answer: C

Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.

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