Nursing Elites

1. When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?

• A. A halo of erythema on the surrounding skin
• B. Presence of serous drainage
• C. Edema around the wound
• D. Absence of granulation tissue

Correct answer: A

Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.

2. A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client’s room to administer medications and finds the client crying. The appropriate nursing action is to:

• A. Sit and hold the client’s hand
• B. Ask why the client is crying
• C. Leave the room to give the client privacy
• D. Administer the medications and leave

Correct answer: A

Rationale: In end-of-life care, providing comfort and emotional support is essential. Sitting with the client, holding their hand, and offering a compassionate presence can help the client feel supported during a difficult time. Asking why the client is crying may not always be necessary as the focus should be on providing comfort rather than probing for information. Leaving the room to provide privacy or just administering medications and leaving may neglect the client's emotional needs and miss an opportunity to provide holistic care.

3. A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?

• A. Heart rate of 52 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Blood glucose level of 180 mg/dL
• D. Potassium level of 4.0 mEq/L

Correct answer: A

Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.

4. The healthcare provider is assessing a client with a diagnosis of asthma. Which assessment finding would be most concerning?

• A. Wheezing
• B. Shortness of breath
• C. Use of accessory muscles
• D. Cough with sputum production

Correct answer: C

Rationale: The most concerning assessment finding in a client with asthma is the use of accessory muscles. This indicates that the client is working harder to breathe, which could signify respiratory distress. Wheezing, choice A, is a common finding in asthma and indicates narrowed airways but may not necessarily imply immediate distress. Shortness of breath, choice B, is also common in asthma but may not be as concerning as the use of accessory muscles. Cough with sputum production, choice D, can occur in asthma exacerbations but may not be as critical as signs of increased work of breathing like the use of accessory muscles.

5. A client in the terminal stage of cancer is crying. What action should the nurse take?

• A. Sit and hold the client's hand
• B. Encourage the client to talk about their feelings
• C. Leave the client alone to cry
• D. Ignore the client's crying

Correct answer: A

Rationale: In situations where a client is in the terminal stage of cancer and crying, it is essential for the nurse to provide comfort and support. Sitting with the client and holding their hand can offer a sense of presence and emotional support, showing empathy and understanding. Encouraging the client to talk about their feelings (choice B) is also important, but initially, non-verbal support through physical presence can be comforting. Leaving the client alone to cry (choice C) can make the client feel abandoned and unsupported during a vulnerable moment. Ignoring the client's crying (choice D) is not appropriate and lacks compassion and empathy, which are crucial in end-of-life care.

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