Nursing Elites

1. A client with atrial fibrillation is receiving digoxin (Lanoxin) and warfarin (Coumadin). Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Heart rate of 58 beats per minute
• B. Presence of a new murmur
• C. INR of 2.5
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. The presence of a new murmur in a client with atrial fibrillation may indicate a valvular problem or other complications, requiring immediate reporting. A heart rate of 58 beats per minute is within the normal range for some individuals with atrial fibrillation, so it is not an immediate concern. An INR of 2.5 is within the therapeutic range for a client on warfarin, indicating appropriate anticoagulation. A blood pressure of 110/70 mmHg is also within the normal range and does not pose an immediate threat to the client's health.

2. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. What action should the nurse take?

• A. Encourage the UAP to remain in the client's room until the hand rub is completed.
• B. Explain that the hand rub can be completed in less than 2 minutes.
• C. Inform the UAP that handwashing helps to promote better asepsis.
• D. Determine why the UAP was not wearing gloves in the client's room.

Correct answer: B

Rationale: The correct answer is B. Alcohol-based hand rubs are effective with a shorter rub time, typically around 20-30 seconds. Standing at the bedside for 2 minutes to rub hands thoroughly is unnecessary and can lead to wastage of resources. It's essential for the nurse to educate the UAP on proper hand hygiene techniques to ensure efficient and effective infection control practices. Choices A, C, and D are incorrect because encouraging the UAP to remain in the client's room, discussing handwashing instead of hand rubs, and questioning glove use are not the most appropriate actions in this scenario.

3. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.

4. The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?

• A. Slight difficulty swallowing
• B. Hoarse voice
• C. Positive Chvostek's sign
• D. Pain at the incision site

Correct answer: C

Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.

5. The nurse is assessing a client with left-sided heart failure. Which finding requires immediate intervention?

• A. Shortness of breath
• B. Jugular venous distention
• C. Crackles in the lungs
• D. Peripheral edema

Correct answer: C

Rationale: Crackles in the lungs indicate pulmonary congestion in a client with left-sided heart failure and require immediate intervention to prevent respiratory failure. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potentially respiratory distress. Shortness of breath, jugular venous distention, and peripheral edema are common manifestations of heart failure but do not directly indicate acute respiratory compromise like crackles in the lungs do.

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