Nursing Elites

1. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote

• A. Relaxation and sleep
• B. Deep breathing and coughing
• C. Incisional healing
• D. Range of motion exercises

Correct answer: B

Rationale: Effective pain management encourages deep breathing and coughing, which are crucial for preventing complications after thoracic surgery. These actions help prevent respiratory complications such as pneumonia and atelectasis, promote lung expansion, and improve oxygenation. While relaxation and sleep are important for recovery, the priority after a thoracotomy and lobectomy is to prevent respiratory issues. Incisional healing is important but not the primary focus immediately post-surgery. Range of motion exercises are not directly related to promoting recovery after thoracic surgery.

2. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

• A. Blood urea nitrogen 50 mg/dl
• B. Hemoglobin of 10.3 g/dl
• C. Venous blood pH 7.30
• D. Serum potassium 6 mEq/L

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

3. A nurse is reinforcing nutrition teaching with a client who has osteoporosis. Which of the following food selections should the nurse recommend to increase calcium in the client's diet?

• A. 1 medium apple
• B. 3 oz of lean beef
• C. 1 tbsp of cream cheese
• D. 1 cup of kale

Correct answer: D

Rationale: The correct answer is D: 1 cup of kale. Kale is rich in calcium, making it a suitable choice to increase calcium intake for individuals with osteoporosis. While fruits like apples (choice A) are nutritious, they are not high in calcium. Lean beef (choice B) is a good source of protein but not a significant source of calcium. Cream cheese (choice C) is also not a primary source of calcium compared to kale.

4. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

• A. Orthostatic hypotension is a common side effect.
• B. Most antipsychotic drugs cause elevated blood pressure.
• C. This provides information on the amount of sodium allowed in the diet.
• D. It will indicate the need to institute anti-parkinsonian drugs.

Correct answer: A

Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.

5. When assessing a client for signs and symptoms of a fluid volume deficit, the nurse would be most concerned with which finding?

• A. Blood pressure of 90/60 mm Hg
• B. Heart rate of 110 beats per minute
• C. Respiratory rate of 24 breaths per minute
• D. Urine output of 30 mL per hour

Correct answer: A

Rationale: Corrected Rationale: A low blood pressure of 90/60 mm Hg is a significant finding indicating fluid volume deficit. In fluid volume deficit, the body tries to compensate by increasing heart rate (choice B) to maintain cardiac output. Respiratory rate (choice C) may increase as a compensatory mechanism, but it is not the primary concern in fluid volume deficit. Urine output (choice D) may decrease in response to fluid volume deficit, but it is a late sign and not the most concerning finding.

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