Nursing Elites

1. A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?

• A. Irregular apical pulse
• B. Purple marks on the skin of the abdomen
• C. Quarter-sized blood spot on the dressing
• D. Pitting ankle edema

Correct answer: A

Rationale: The correct answer is A: Irregular apical pulse. In a client recovering from a laparoscopic procedure with Cushing's Syndrome, an irregular apical pulse can be indicative of a life-threatening arrhythmia and requires immediate intervention. Choices B, C, and D are not as urgent as an irregular apical pulse. Purple marks on the skin of the abdomen may be related to Cushing's Syndrome, a quarter-sized blood spot on the dressing can be managed with appropriate wound care, and pitting ankle edema may be expected postoperatively but does not require immediate intervention.

2. A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

• A. Report when hematuria becomes pink-tinged
• B. Use incentive spirometer
• C. Restrict physical activities
• D. Monitor urinary stream for a decrease in output

Correct answer: D

Rationale: After lithotripsy, monitoring the urinary stream for a decrease in output is essential to identify any potential complications such as urinary retention or obstruction. Reporting pink-tinged hematuria is important, but monitoring the urinary stream for a decrease in output takes precedence as it directly assesses renal function and potential complications. Using an incentive spirometer is not directly related to post-lithotripsy care. Restricting physical activities may be necessary initially but is not the priority compared to monitoring urinary output.

3. While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values?

• A. Neutrophil count.
• B. Hematocrit.
• C. Blood pH.
• D. Serum potassium and sodium.

Correct answer: A

Rationale: The correct answer is A: Neutrophil count. Neutrophil count helps assess for infection, which is indicated by the redness, tenderness, and swelling of the wound. Elevated neutrophil count is a common sign of bacterial infection. Hematocrit (choice B) measures the proportion of blood volume that is occupied by red blood cells and is not directly related to wound infection. Blood pH (choice C) and serum potassium and sodium (choice D) are important for assessing acid-base balance and electrolyte levels but are not the primary indicators of wound infection.

4. In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?

• A. Yellow.
• B. Black.
• C. Red.
• D. Green.

Correct answer: A

Rationale: A yellow triage tag should be placed on the client with partial-thickness burns covering 10% of his lower body. Yellow tags indicate delayed treatment, suitable for serious injuries that are not immediately life-threatening. Black tags are used for deceased individuals, red tags for immediate treatment of life-threatening injuries, and green tags for minor injuries.

5. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure?

• A. Light yellow coloring of the client's skin and eyes.
• B. The client's blood pressure reading of 184/88 mm Hg.
• C. The client vomits 20 ml of clear yellowish fluid.
• D. The IV insertion site is red, swollen, and leaking IV fluid.

Correct answer: B

Rationale: The correct answer is B. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risks associated with surgery. The healthcare provider should be notified to manage the blood pressure before proceeding with the scheduled procedure. Choices A, C, and D are incorrect: A, light yellow coloring of the client's skin and eyes may indicate jaundice, but it is not an immediate concern for the scheduled procedure; C, vomiting clear yellowish fluid may suggest bile reflux, but it does not pose an immediate risk to the procedure; D, red, swollen, and leaking IV insertion site indicates a local complication that requires intervention but does not have a direct impact on proceeding with the scheduled surgery.

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