Nursing Elites

1. A nurse is caring for a client who is 1 hour postoperative following a thoracentesis. Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 96%
• B. Tracheal deviation
• C. Pain level of 4 on a scale of 0 to 10
• D. Temperature of 37.4°C (99.3°F)

Correct answer: B

Rationale: Tracheal deviation is the correct finding to report to the provider. It can indicate a pneumothorax, which is a serious complication following a thoracentesis that requires immediate attention. Oxygen saturation of 96% is within the normal range and does not indicate an immediate issue. A pain level of 4 on a scale of 0 to 10 is subjective and may not be related to a serious complication. A temperature of 37.4°C (99.3°F) is slightly elevated but not a priority over tracheal deviation in this context.

2. A client who has a new diagnosis of hypertension is being taught about dietary modifications by a nurse. Which of the following instructions should the nurse include?

• A. Limit fluid intake to 2 liters per day.
• B. Increase your intake of whole grains.
• C. Eat 3 large meals daily.
• D. Consume foods high in potassium.

Correct answer: B

Rationale: The correct answer is B: 'Increase your intake of whole grains.' Whole grains are beneficial for individuals with hypertension as they can help promote heart health. Whole grains are high in fiber, which can help lower blood pressure. Option A is incorrect as fluid intake should be adequate but not restricted to 2 liters per day. Option C is incorrect as it is recommended to have smaller, more frequent meals rather than 3 large meals to help manage hypertension. Option D is incorrect; although foods high in potassium can be beneficial for hypertension, the most appropriate dietary modification to include in this scenario is increasing whole grain intake.

3. Which lab value should be closely monitored for a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor potassium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.

4. While caring for a client receiving an opioid analgesic for pain management, which assessment should the nurse prioritize?

• A. Monitor the client's urinary output.
• B. Check the client's blood pressure.
• C. Assess the client for constipation.
• D. Monitor the client's respiratory rate.

Correct answer: D

Rationale: The correct answer is to monitor the client's respiratory rate. When a client is receiving opioids, the priority assessment is the respiratory rate since opioids can lead to respiratory depression. Monitoring urinary output, blood pressure, and constipation are also important but not the priority in this scenario.

5. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following actions should the provider take?

• A. Insert the needle at a 90-degree angle
• B. Insert the needle at a 45-degree angle
• C. Inject the medication slowly after aspiration
• D. Massage the site after injection

Correct answer: A

Rationale: Correct answer: When administering an intramuscular injection, the needle should be inserted at a 90-degree angle to ensure proper delivery of the medication into the muscle tissue. Option B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Option C is incorrect as aspiration is not recommended for intramuscular injections. Option D is incorrect as massaging the site after an intramuscular injection can cause tissue damage or interfere with the absorption of the medication.

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