Nursing Elites

1. A nurse is caring for a client who has Raynaud's disease. What intervention should the nurse implement?

• A. Provide information about stress management.
• B. Maintain a cool temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: The correct intervention for a client with Raynaud's disease is to provide information about stress management. Stress management techniques can help reduce the frequency and severity of Raynaud's episodes. Choice B is incorrect because maintaining a cool temperature can exacerbate symptoms in individuals with Raynaud's disease. Choice C is incorrect as epinephrine is not typically used for Raynaud's disease. Choice D is incorrect as glucocorticoid steroids are not the first-line treatment for Raynaud's disease.

2. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider?

• A. The client's pulse oximetry level is 96%.
• B. The client develops hiccups.
• C. The ECG shows pacing spikes after the QRS complex.
• D. The client's heart rate is 90 beats per minute.

Correct answer: C

Rationale: The correct answer is C. Pacing spikes after the QRS complex indicate a malfunction of the pacemaker and should be reported. Choice A is not directly related to the pacemaker function. Choice B, hiccups, are common and not typically associated with pacemaker issues. Choice D, a heart rate of 90 beats per minute, is within the normal range and does not indicate a pacemaker malfunction.

3. A nurse is caring for a client who is 12 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Respiratory rate of 16/min.
• C. Heart rate of 90/min.
• D. WBC count of 15,000/mm3.

Correct answer: D

Rationale: A WBC count of 15,000/mm3 is elevated, which may indicate infection, a common concern postoperatively. An elevated WBC count suggests the body is fighting an infection, and prompt reporting to the provider is essential for further evaluation and treatment. Serosanguineous drainage on the surgical dressing is expected in the immediate postoperative period, respiratory rate of 16/min is within the normal range, and a heart rate of 90/min is also within an acceptable range postoperatively. Therefore, these findings do not raise immediate concerns that necessitate reporting to the provider.

4. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Redness and warmth in the calf
• C. Oxygen saturation of 95%
• D. Temperature of 37.3°C (99.1°F)

Correct answer: B

Rationale: Redness and warmth in the calf can indicate a blood clot, specifically deep vein thrombosis (DVT), which is a serious complication post hip arthroplasty. The warmth and redness are signs of inflammation due to the clot formation. DVT can lead to a pulmonary embolism if not addressed promptly. Monitoring for this complication is crucial in postoperative care. Elevated heart rate, oxygen saturation within normal limits, and a slightly elevated temperature are common findings postoperatively and may not be alarming in the absence of other concerning symptoms.

5. How should a healthcare provider respond to a patient refusing a blood transfusion for religious reasons?

• A. Respect the patient's beliefs
• B. Educate the patient on the importance of the transfusion
• C. Notify the healthcare provider
• D. Persuade the patient to accept the transfusion

Correct answer: A

Rationale: When a patient refuses a blood transfusion for religious reasons, the healthcare provider should respect the patient's beliefs. It is crucial to uphold the patient's autonomy and right to make decisions about their care, even if the provider disagrees. Educating the patient on the importance of the transfusion may be appropriate in some cases, but the initial response should always be to respect the patient's decision. Notifying the healthcare provider is not necessary as the decision lies with the patient. Persuading the patient to accept the transfusion goes against the principle of respecting the patient's autonomy and beliefs.

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