Nursing Elites

1. A client has a sodium level of 125. What findings should the nurse expect?

• A. Abdominal cramping
• B. Elevated blood pressure
• C. Decreased heart rate
• D. Increased thirst

Correct answer: A

Rationale: Low sodium levels (hyponatremia) often present with various symptoms, including abdominal cramping. Abdominal cramping is a common manifestation of hyponatremia due to the altered electrolyte balance. Option B ('Elevated blood pressure') is incorrect because low sodium levels typically lead to decreased blood pressure, not elevated. Option C ('Decreased heart rate') is incorrect as low sodium levels are more likely to cause an irregular heart rate rather than a decreased heart rate. Option D ('Increased thirst') is incorrect because excessive thirst is more commonly associated with high sodium levels (hypernatremia) rather than low sodium levels.

2. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

• A. The family member washes out the feeding bag with warm water once every 24 hours.
• B. The family member washes out the feeding bag with hot water once every 24 hours.
• C. The family member washes out the feeding bag with soap and water every 24 hours.
• D. The family member changes the feeding bag every 24 hours.

Correct answer: A

Rationale: The correct answer is A. Washing out the feeding bag with warm water once every 24 hours is not sufficient to prevent bacterial growth and can lead to diarrhea. Using hot water may damage the feeding bag. Washing out the feeding bag with soap and water every 24 hours is excessive and may leave residue that could be harmful. Changing the feeding bag every 24 hours is important for preventing infections but does not directly address the issue of diarrhea in this case.

3. Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?

• A. Notify the nurse manager
• B. Continue monitoring as instructed
• C. Administer IV fluids as per protocol
• D. Prepare for immediate transfer to the ICU

Correct answer: B

Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.

4. The healthcare provider is assessing a client who has a chest tube in place following a pneumothorax. Which finding should be reported to the healthcare provider immediately?

• A. Bubbling in the water seal chamber
• B. Drainage greater than 70 ml/hour
• C. Tidaling in the water seal chamber
• D. Absence of breath sounds on the affected side

Correct answer: D

Rationale: The absence of breath sounds on the affected side is a critical finding that may indicate a tension pneumothorax, a life-threatening condition requiring immediate intervention. This situation can lead to a shift of the mediastinum and impaired ventilation. Bubbling in the water seal chamber is an expected finding in a chest tube drainage system and indicates proper functioning. Drainage greater than 70 ml/hour is a concern but does not require immediate reporting unless it continues at a high rate or is associated with other symptoms. Tidaling in the water seal chamber is a normal fluctuation and indicates the chest tube system is patent and functioning correctly.

5. A guardian reports that a 4-year-old child is waking up with nightmares. Which of the following interventions should the nurse suggest?

• A. Offer the child a large snack before bedtime.
• B. Allow the child to watch an extra 30 minutes of TV in the evening.
• C. Have the child go to bed at a consistent time every day.
• D. Increase physical activity before bedtime.

Correct answer: C

Rationale: The correct answer is to have the child go to bed at a consistent time every day. Consistent bedtime routines can help reduce nightmares by providing the child with a sense of security and stability. Offering a large snack before bedtime or allowing extra TV time may disrupt sleep patterns and lead to nightmares. Increasing physical activity before bedtime could have the opposite effect and make it harder for the child to fall asleep.

Similar Questions