Nursing Elites

1. While caring for a client with an arterial line, which of the following actions should the nurse take?

• A. Level the transducer with the client's phlebotomy site
• B. Flush the arterial line every 8 hours
• C. Obtain a blood sample for arterial blood gases
• D. Keep the client's hand elevated above the heart level

Correct answer: C

Rationale: Obtaining arterial blood gases is a crucial nursing action when caring for a client with an arterial line. This procedure helps assess the client's oxygenation status and acid-base balance accurately. Leveling the transducer with the client's phlebotomy site (A) is important for accurate pressure measurements, but it is not the primary action in this scenario. Flushing the arterial line every 8 hours (B) is a routine maintenance procedure and not the immediate priority. Keeping the client's hand elevated above the heart level (D) is a good practice to prevent swelling, but it is not directly related to the arterial line care in this case.

2. A nurse is caring for a client who has a new diagnosis of rheumatoid arthritis. Which of the following laboratory findings should the nurse expect?

• A. Increased WBC count.
• B. Decreased hemoglobin.
• C. Decreased platelet count.
• D. Positive rheumatoid factor.

Correct answer: D

Rationale: The correct answer is D: Positive rheumatoid factor. A positive rheumatoid factor is a common laboratory finding in clients with rheumatoid arthritis, indicating an autoimmune response. Option A, increased WBC count, is not typically associated with rheumatoid arthritis. Option B, decreased hemoglobin, and option C, decreased platelet count, are not specific laboratory findings for rheumatoid arthritis.

3. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased skin turgor.
• C. Tachycardia.
• D. Bounding pulse.

Correct answer: C

Rationale: The correct answer is C: Tachycardia. Tachycardia is a common sign of dehydration because the body tries to compensate for the reduced fluid volume by increasing the heart rate. Bradycardia (choice A) is not typically seen in dehydration as the body tries to maintain perfusion. Increased skin turgor (choice B) is actually a sign of dehydration, but tachycardia is a more specific finding. A bounding pulse (choice D) is associated with conditions like hyperthyroidism or aortic regurgitation, not dehydration.

4. A client is taking sucralfate. Which of the following client statements indicates an understanding of the teaching?

• A. I should take this medication 1 hour before meals.
• B. I should take this medication 30 minutes after meals.
• C. I should take this medication only when I have symptoms of heartburn.
• D. I should take this medication with a glass of milk.

Correct answer: A

Rationale: The correct answer is A. Sucralfate is most effective when taken 1 hour before meals to protect the stomach lining. Option B is incorrect because sucralfate should not be taken after meals. Option C is incorrect because sucralfate is typically taken on a regular schedule, not just when symptoms occur. Option D is incorrect because sucralfate should not be taken with milk, as it can interfere with its effectiveness.

5. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

• A. Chest pain
• B. Muscle spasms
• C. Cool, moist skin
• D. Incisional pain

Correct answer: A

Rationale: In a client who is 30 minutes postoperative following an arterial thrombectomy, chest pain is a critical finding that should be reported immediately. Chest pain can indicate serious complications such as myocardial infarction or pulmonary embolism, which require prompt intervention. Muscle spasms and cool, moist skin are not typical signs of immediate concern following an arterial thrombectomy. Incisional pain is expected postoperatively and may not warrant immediate reporting unless accompanied by other concerning symptoms.

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