Nursing Elites

1. A client complains of paresthesia in the fingers and toes and experiences hand spasms when the blood pressure cuff is inflated. Which serum laboratory finding should the nurse expect to find when assessing the client?

• A. Elevated serum calcium
• B. Low serum magnesium
• C. Low serum calcium
• D. Elevated serum potassium

Correct answer: C

Rationale: The correct answer is C: Low serum calcium. Hand spasms and paresthesia are indicative of potential hypocalcemia, which is characterized by low serum calcium levels. Elevated serum calcium (Choice A) is not consistent with the symptoms described. Low serum magnesium (Choice B) and elevated serum potassium (Choice D) are not typically associated with hand spasms and paresthesia.

2. The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

• A. Gunshot wound three hours ago with dark drainage of 2 cm on the dressing
• B. Mastectomy 2 days ago with 50 ml bloody drainage in the Jackson-Pratt drain
• C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
• D. Abdominal-perineal resection 2 days ago with no drainage on dressing and fever and chills

Correct answer: C

Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.

3. Identify the placement of the stapes footplate into the bony labyrinth.

• A. Fenestra vestibuli
• B. Fenestra cochleae
• C. Tympanic membrane
• D. Round window

Correct answer: A

Rationale: The correct answer is A: Fenestra vestibuli. The stapes footplate is placed into the fenestra vestibuli of the bony labyrinth. This structure is also known as the oval window and is located at the junction of the middle ear and inner ear. Choice B, Fenestra cochleae, is incorrect as this opening is also known as the round window and is located near the base of the cochlea. Choice C, Tympanic membrane, is incorrect as it is also known as the eardrum and separates the external ear from the middle ear. Choice D, Round window, is incorrect as it is the opening covered by the secondary tympanic membrane and is important for the dissipation of sound waves in the cochlea.

4. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

• A. Check the visual difficulties
• B. Note the most recent hemoglobin level
• C. Assess for hand and joint pain
• D. Observe rhythm on telemetry monitor

Correct answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

5. In a client in her third trimester of pregnancy, an S3 heart sound is auscultated. What intervention should the nurse take?

• A. Notify the healthcare provider
• B. Limit the client’s fluids
• C. Prepare the client for an echocardiogram
• D. Document in the client’s record

Correct answer: D

Rationale: An S3 heart sound can be a normal finding in pregnancy due to increased blood volume and flow. In this scenario, there is no immediate need for further interventions. Documenting this finding in the client's record is essential for tracking the client's health status and ensuring proper follow-up if needed. Notifying the healthcare provider, limiting fluids, or preparing for an echocardiogram is unnecessary as it is likely a physiological finding in pregnancy. These interventions should only be considered if other symptoms suggestive of a cardiac issue are present.

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