Nursing Elites

1. A client had a bronchoscopy 2 hours ago and asks for a drink of water. Which action should the nurse take next?

• A. Call the healthcare provider to request a prescription for food and water.
• B. Provide the client with ice chips instead of a drink of water.
• C. Assess the client's gag reflex before giving any food or water.
• D. Let the client have a small sip to assess swallowing ability.

Correct answer: C

Rationale: After a bronchoscopy, a topical anesthetic affects the gag reflex. Therefore, the nurse should assess the client's gag reflex before providing any food or water to ensure its return. This assessment is crucial to prevent aspiration or choking risk in the client.

2. A client takes atorvastatin (Lipitor), with laboratory results showing a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

• A. Ask if the client eats grapefruit.
• B. Assess the client for dehydration.
• C. Facilitate admission to the hospital.
• D. Obtain a random urinalysis.

Correct answer: A

Rationale: There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. The client has elevated renal laboratory results, indicating kidney involvement. The nurse should ask if the client consumes grapefruit or grapefruit juice. While dehydration can elevate BUN, the increase in creatinine is more specific for kidney injury.

3. A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?

• A. Widened QRS complexes
• B. Hyperactive deep tendon reflexes
• C. Bounding peripheral pulses
• D. Warm, flushed skin

Correct answer: A

Rationale: Respiratory acidosis is a condition characterized by increased carbon dioxide levels in the blood, resulting in acidosis. One of the potential consequences of respiratory acidosis is the development of electrolyte imbalances, particularly hyperkalemia. Hyperkalemia can lead to cardiac conduction abnormalities, manifested as widened QRS complexes on an electrocardiogram (ECG). Therefore, in a client with respiratory acidosis, the healthcare professional should expect to find widened QRS complexes as a result of the associated hyperkalemia.

4. A client who is receiving mechanical ventilation and has an ideal weight of 60 kg should have the tidal volume set at which of the following?

• A. 300 mL
• B. 480 mL
• C. 800 mL
• D. 950 mL

Correct answer: B

Rationale: Tidal volume is the amount of air delivered with each breath during mechanical ventilation. A common formula used to calculate tidal volume is 6-8 mL/kg of ideal body weight. For a client with an ideal weight of 60 kg, the expected tidal volume would be 60 kg x 6-8 mL/kg = 360-480 mL. Therefore, the most appropriate choice is 480 mL (Option B), which falls within the expected range based on the client's weight.

5. A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?

• A. Administer an IV fluid bolus.
• B. Check the surgical site for bleeding.
• C. Place the client in a Trendelenburg position.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: Checking the surgical site for bleeding is crucial in this situation as it helps determine if the drop in blood pressure is due to hemorrhage, a potential postoperative complication. Identifying and addressing bleeding promptly is essential to prevent further complications and stabilize the client's condition.

Similar Questions