Nursing Elites

1. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?

• A. 240 ml
• B. 500 ml
• C. 760 ml
• D. 1000 ml

Correct answer: C

Rationale: The correct answer is 760 ml. After vomiting 240 ml (1 cup), the nurse should document the remaining 760 ml as the fluid intake. Choice A (240 ml) is the amount vomited, not the total intake. Choice B (500 ml) and Choice D (1000 ml) are the total intake, not considering the vomiting.

2. The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?

• A. Stay with the client throughout the infusion.
• B. Keep emergency resuscitation equipment at the bedside.
• C. Obtain the client's allergy history.
• D. Ask the client about past allergic reactions to medications.

Correct answer: B

Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.

3. The nurse is assessing the thorax and lungs of a client who is experiencing respiratory difficulty. Which finding is most indicative of respiratory distress?

• A. Contractions of the sternocleidomastoid muscle.
• B. Respiratory rate of 20 breaths/min
• C. Downward movement of diaphragm with inspiration
• D. A pulse oximetry reading of SpO2 95%

Correct answer: A

Rationale: The correct answer is A: Contractions of the sternocleidomastoid muscle. Contractions of the sternocleidomastoid muscle suggest that the client is using accessory muscles to breathe, which is a clear sign of respiratory distress. This finding indicates that the client is working harder to breathe, typically seen in conditions like asthma, COPD, or respiratory failure. Choices B, C, and D are not the most indicative of respiratory distress. A respiratory rate of 20 breaths/min falls within the normal range. Downward movement of the diaphragm with inspiration is a normal finding indicating effective diaphragmatic breathing. A pulse oximetry reading of SpO2 95% is within the normal range and does not necessarily indicate respiratory distress.

4. The nurse is caring for a client who is postoperative following a thyroidectomy. Which finding requires immediate intervention?

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

Correct answer: C

Rationale: A positive Chvostek's sign indicates hypocalcemia, a common complication following thyroidectomy due to inadvertent parathyroid gland injury. Immediate intervention is needed to prevent severe hypocalcemia symptoms like tetany, seizures, and laryngospasm. Hoarse voice and slight difficulty swallowing are expected post-thyroidectomy and do not require immediate intervention. Pain at the incision site is common postoperatively and can be managed with appropriate pain relief measures.

5. The nurse notes that a client who has undergone a thoracotomy has an increase in a large amount of dark red blood in the chest tube collection chamber. What action should the nurse take?

• A. Document the findings for this procedure as expected
• B. Notify the healthcare provider immediately
• C. Check the tube for kinks or dependent loops
• D. Increase the suction to the chest drainage system

Correct answer: B

Rationale: An increase in a large amount of dark red blood in the chest tube collection chamber may indicate active bleeding. The nurse should notify the healthcare provider immediately to address the situation promptly and prevent further complications. Documenting the findings without taking immediate action could delay necessary interventions. Checking the tube for kinks or dependent loops is a good practice but not the priority when dealing with a potentially life-threatening situation like active bleeding. Increasing the suction without healthcare provider's orders can lead to complications and is not appropriate in this scenario.

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