Nursing Elites

1. A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?

• A. Disorientation and dyspnea
• B. Drowsiness, headache, and tachypnea
• C. Tachypnea, dizziness, and paresthesias
• D. Dysrhythmias and decreased respiratory rate and depth

Correct answer: C

Rationale: The correct answer is C: Tachypnea, dizziness, and paresthesias. When a client is anxious, they may hyperventilate, leading to respiratory alkalosis. Tachypnea (rapid breathing) is a common sign of respiratory alkalosis. Dizziness and paresthesias (tingling or numbness in the extremities) are also typical symptoms. Choices A, B, and D are incorrect. Disorientation and dyspnea (Choice A) are not specific signs of respiratory alkalosis. Drowsiness, headache, and tachypnea (Choice B) may be more indicative of other conditions. Dysrhythmias and decreased respiratory rate and depth (Choice D) are not consistent with the expected signs of respiratory alkalosis.

2. A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless, and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:

• A. Notify the surgeon
• B. Continue the assessment
• C. Check the client’s blood pressure
• D. Obtain a flashlight, gauze, and a curved hemostat

Correct answer: A

Rationale: In the scenario described, the client's presentation with bright-red blood vomiting after a tonsillectomy and adenoidectomy is highly concerning for an immediate postoperative hemorrhage, which can be life-threatening. The priority action for the nurse is to notify the surgeon immediately. Prompt communication with the surgeon is vital to ensure swift intervention and appropriate management to address the hemorrhage effectively. Continuing the assessment, checking the client's blood pressure, or obtaining equipment are all secondary actions in this critical situation and would delay the necessary urgent intervention required to manage the hemorrhage effectively.

3. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?

• A. I am having fewer aches and pains.
• B. I do not have headaches anymore.
• C. I am able to walk further without leg pain.
• D. My toes are turning grayish black in color.

Correct answer: C

Rationale: The correct answer is C. Cilostazol improves blood flow to the muscles, which helps alleviate symptoms of intermittent claudication. An improvement in walking distance without leg pain indicates the effectiveness of the medication. Choices A and B are not directly related to the expected outcome of Cilostazol therapy for intermittent claudication. Choice D is concerning for a potential adverse effect and should be reported to the healthcare provider immediately.

4. What is the primary nursing intervention for a patient experiencing an acute asthma attack?

• A. Administering bronchodilators.
• B. Administering antibiotics.
• C. Administering IV fluids.
• D. Administering corticosteroids.

Correct answer: A

Rationale: The correct answer is administering bronchodilators. During an acute asthma attack, the primary goal is to relieve airway constriction and bronchospasm to improve breathing. Bronchodilators, such as short-acting beta-agonists, are the cornerstone of treatment as they help dilate the airways quickly. Administering antibiotics (choice B) is not indicated unless there is an underlying bacterial infection. Administering IV fluids (choice C) may be necessary in some cases, but it is not the primary intervention for an acute asthma attack. Administering corticosteroids (choice D) is often used as an adjunct therapy to reduce airway inflammation, but it is not the primary intervention during the acute phase of an asthma attack.

5. A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply.

• A. Hematocrit 30%
• B. Sodium 141 mEq/L
• C. Hemoglobin 8.9 g/dL
• D. Platelets 210,000 cells/mm3

Correct answer: C

Rationale: The correct answer is C. Hemoglobin level of 8.9 g/dL is below the normal range, indicating anemia. Anemia can affect the body's ability to carry oxygen, impacting surgical outcomes. Hematocrit level is an indirect measure of red blood cells, which also reveals anemia when low. Sodium level of 141 mEq/L and platelet count of 210,000 cells/mm3 are within normal ranges and do not require immediate reporting. Abnormal sodium levels can lead to various issues, but in this scenario, it is not a concern for surgical readiness. Platelet count is vital for blood clotting, and a count of 210,000 cells/mm3 is considered normal, so it does not need urgent attention.

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