Nursing Elites

1. A nurse is assessing a client who has myasthenia gravis. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased muscle strength.
• C. Diarrhea.
• D. Decreased deep tendon reflexes.

Correct answer: D

Rationale: The correct answer is D: Decreased deep tendon reflexes. In myasthenia gravis, muscle weakness is a common manifestation, leading to decreased deep tendon reflexes. Bradycardia (choice A) is not typically associated with myasthenia gravis. Increased muscle strength (choice B) is unlikely as muscle weakness is a hallmark of this condition. Diarrhea (choice C) is not a typical finding in myasthenia gravis.

2. A client is postoperative following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypocalcemia?

• A. Constipation
• B. Numbness and tingling of the fingers
• C. Increased thirst
• D. Frequent urination

Correct answer: B

Rationale: Numbness and tingling of the fingers are classic signs of hypocalcemia, a condition that may result from inadvertent damage to the parathyroid glands during a thyroidectomy. These symptoms occur due to decreased levels of calcium in the bloodstream affecting nerve function. Choices A, C, and D are not typical manifestations of hypocalcemia. Constipation is more associated with hypercalcemia, increased thirst can be seen in diabetes or dehydration, and frequent urination is a symptom more commonly linked to conditions like diabetes or urinary tract issues.

3. A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?

• A. Perform chest physiotherapy every 4 hours.
• B. Suction the client every 2 hours.
• C. Encourage the client to increase fluid intake.
• D. Administer oxygen via nasal cannula.

Correct answer: C

Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.

4. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?

• A. Open sterile packages using the flap closest to your body first.
• B. Don sterile gloves before opening the sterile package.
• C. Avoid reaching over the sterile field.
• D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.

Correct answer: C

Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.

5. While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?

• A. Ensure the eye shield is covering the eyes.
• B. Apply lotion to the exposed skin.
• C. Offer glucose water between feedings.
• D. Discontinue breastfeeding during treatment.

Correct answer: A

Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.

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