Nursing Elites

1. A client post-thyroidectomy reports tingling in their lips and fingers. The nurse should identify this finding as an indication of which of the following complications?

• A. Hypokalemia
• B. Hypocalcemia
• C. Hyponatremia
• D. Hyperglycemia

Correct answer: B

Rationale: Tingling in the lips and fingers is a classic sign of hypocalcemia, which can occur as a complication following a thyroidectomy due to inadvertent damage to the parathyroid glands that regulate calcium levels. Hypokalemia (Choice A) presents with muscle weakness and cardiac issues, not tingling. Hyponatremia (Choice C) typically manifests with confusion, seizures, and muscle cramps. Hyperglycemia (Choice D) is associated with increased thirst, frequent urination, and fatigue.

2. A client with a nasogastric tube receiving continuous enteral feedings is at risk for aspiration. Which of the following actions should the nurse take to prevent aspiration?

• A. Elevate the head of the bed to 15 degrees
• B. Check gastric residual volumes every 6 hours
• C. Monitor the pH of gastric aspirate
• D. Instill 10 mL of air into the tube before feeding

Correct answer: B

Rationale: Checking gastric residual volumes every 6 hours is essential in preventing aspiration in clients receiving continuous enteral feedings. This practice helps determine if the stomach is adequately emptying, reducing the risk of regurgitation and aspiration. Elevating the head of the bed to 30 degrees, not 15 degrees, is recommended to further prevent aspiration by reducing the risk of reflux. Monitoring the pH of gastric aspirate is important to assess tube placement but does not directly prevent aspiration. Instilling air into the tube before feeding is not a recommended practice and does not prevent aspiration.

3. A client with schizophrenia is experiencing delusions. Which of the following actions should the nurse take?

• A. Encourage the client to discuss the delusions.
• B. Tell the client that the delusions are not real.
• C. Avoid discussing the delusions with the client.
• D. Challenge the client's delusions directly.

Correct answer: B

Rationale: Telling the client that their delusions are not real is the most appropriate action as it helps ground them in reality without reinforcing the delusion. Encouraging the client to discuss the delusions (choice A) may further validate or intensify the delusions. Avoiding discussing the delusions (choice C) may lead to the client feeling isolated and unheard. Challenging the client's delusions directly (choice D) can escalate the situation and cause distress to the client.

4. A nurse is assessing a client who is 48 hours postoperative following a hip replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min.
• B. WBC count 15,000/mm3.
• C. Urinary output 75 mL in the past 4 hours.
• D. Temperature 37.8°C (100°F).

Correct answer: B

Rationale: An elevated WBC count 48 hours postoperatively may indicate an infection and should be reported to the provider. Choice A, a heart rate of 90/min, is within normal limits and not a concerning finding postoperatively. Choice C, urinary output of 75 mL in the past 4 hours, may indicate decreased renal perfusion, but an elevated WBC count is a more urgent finding. Choice D, a temperature of 37.8°C (100°F), which is slightly elevated, could be indicative of the body's normal response to surgery and is not as alarming as an elevated WBC count.

5. Which lab value should be monitored in a patient on digoxin?

• A. Monitor potassium levels
• B. Monitor calcium levels
• C. Monitor digoxin levels
• D. Monitor sodium levels

Correct answer: C

Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.

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