Nursing Elites

1. A client has a hemoglobin level of 7 g/dL. Which of the following findings should the nurse expect?

• A. Bounding pulses
• B. Elevated blood pressure
• C. Headache
• D. Pale, cool skin

Correct answer: D

Rationale: Pale, cool skin is a common finding in clients with a hemoglobin level of 7 g/dL due to decreased oxygen carrying capacity. Bounding pulses (Choice A) are not typically associated with low hemoglobin levels. Elevated blood pressure (Choice B) is not a common finding in clients with anemia. While headache (Choice C) can occur with anemia, it is not a specific finding directly related to a hemoglobin level of 7 g/dL.

2. What is a crucial nursing responsibility when caring for a patient with a central line?

• A. Flush the line with saline
• B. Monitor for infection
• C. Monitor fluid balance
• D. Replace the central line

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is a crucial nursing responsibility. This is essential to prevent complications such as bloodstream infections. While flushing the line with saline and monitoring fluid balance are important aspects of care, they are not as critical as monitoring for infection. Replacing the central line is only done when necessary due to complications or at the end of its recommended use.

3. A nurse is reviewing the medical record of a client who has a prescription for spironolactone. Which of the following findings should the nurse report to the provider?

• A. Potassium 5.0 mEq/L
• B. Blood pressure 136/84 mm Hg
• C. Sodium 140 mEq/L
• D. Calcium 9.5 mg/dL

Correct answer: A

Rationale: A potassium level of 5.0 mEq/L is at the upper limit of normal and should be monitored closely in clients taking spironolactone, which is potassium-sparing. Elevated potassium levels can lead to hyperkalemia, especially in individuals on potassium-sparing diuretics like spironolactone. Monitoring and reporting high potassium levels are crucial to prevent potential complications such as cardiac arrhythmias. Blood pressure (choice B), sodium level (choice C), and calcium level (choice D) are not directly related to the use of spironolactone and do not require immediate reporting in this scenario.

4. A nurse is caring for a client who is 4 hours postoperative following an open reduction and internal fixation of the left tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 62/min
• D. Left foot is cool to the touch

Correct answer: D

Rationale: The correct answer is D. A cool left foot indicates impaired circulation, which could be a sign of compartment syndrome or impaired blood flow. This finding should be reported to the provider promptly for further evaluation and intervention. Serous drainage on the dressing is expected postoperatively and is not a concerning finding. A capillary refill of 2 seconds is within the normal range (less than 3 seconds is normal), indicating adequate peripheral perfusion. A heart rate of 62/min is also within the normal range for an adult, suggesting no immediate concern related to the surgery.

5. A client with acute diverticulitis should have which intervention included in the care plan?

• A. Administer a cleansing enema.
• B. Initiate a low-fiber diet.
• C. Apply moist heat to the abdomen.
• D. Provide a clear liquid diet.

Correct answer: B

Rationale: The correct intervention for a client with acute diverticulitis is to initiate a low-fiber diet. A low-fiber diet helps manage acute diverticulitis by reducing irritation to the colon, allowing it to heal. Administering a cleansing enema (Choice A) can worsen diverticulitis by increasing pressure within the colon. Applying moist heat to the abdomen (Choice C) may provide comfort but does not address the underlying cause. Providing a clear liquid diet (Choice D) is not ideal for diverticulitis management as it lacks the necessary nutrients for healing and may not provide enough bulk to prevent further irritation.

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