Nursing Elites

1. A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

• A. Abnormal breath sounds
• B. Cyanosis of the lips
• C. Increasing pulse rate
• D. Pulse oximeter reading of 92%

Correct answer: C

Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.

2. A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

• A. A nurse tied a client's restraints straps to the moveable part of the bed frame.
• B. An assistive personnel placed a surgical mask on a client who has TB before transporting her to radiology.
• C. A nurse administered a medication to a client 30 minutes before the dose is due.
• D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

Correct answer: C

Rationale: The correct answer is C. An incident report should be completed when a nurse administers medication to a client significantly earlier than the scheduled time. This deviation from the prescribed schedule could potentially impact the client's treatment plan and requires documentation for proper evaluation and follow-up. Choices A, B, and D do not necessarily require an incident report. Choice A involves improper restraint application, which is a safety issue but does not directly involve medication administration. Choice B involves a protective measure for a client with TB, which is within the scope of practice for assistive personnel. Choice D describes an increase in IV fluid administration, which may need monitoring but does not necessarily indicate a need for an incident report unless there are specific complications or adverse effects related to the additional fluid.

3. The patient has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

• A. Assess surfaces exposed to the edges of the cast for pressure areas.
• B. Keep the patient's blood pressure low to prevent overperfusion of tissue.
• C. Allow turning in bed to prevent complications.
• D. Encourage the patient's dietary intake to maintain hydration.

Correct answer: A

Rationale: To prevent skin impairment in a patient with a cast, the nurse should assess surfaces exposed to the edges of the cast for pressure areas. This is important to prevent pressure ulcers or skin breakdown. Keeping the patient's blood pressure low (Choice B) is not directly related to preventing skin impairment in this scenario. Allowing turning in bed (Choice C) is essential for preventing complications like pressure ulcers and is not contraindicated. Encouraging the patient's dietary intake (Choice D) to maintain hydration is not directly related to preventing skin impairment associated with a cast.

4. A client is being discharged with a prescription for digoxin (Lanoxin). Which of the following instructions should the nurse include in the discharge teaching?

• A. Take your pulse daily before taking this medication.
• B. Take an extra dose if you miss a dose of this medication.
• C. Take this medication with food.
• D. Avoid eating foods high in potassium while taking this medication.

Correct answer: A

Rationale: The correct answer is A: 'Take your pulse daily before taking this medication.' It is essential for clients taking digoxin to monitor their pulse daily to detect bradycardia, a potential side effect. Choice B is incorrect because clients should never take an extra dose if a dose is missed; they should take the missed dose as soon as remembered unless it is close to the time for the next dose. Choice C is incorrect because digoxin is preferably taken with food to minimize gastrointestinal side effects. Choice D is incorrect because digoxin itself can cause low potassium levels, so avoiding potassium-rich foods is not necessary.

5. A client in an oncology clinic is being assessed by a nurse while undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

• A. I keep having nightmares about my upcoming surgery.
• B. I feel more energetic than I did before.
• C. I have been making plans for the future.
• D. I am looking forward to starting my new treatment.

Correct answer: A

Rationale: Choice A is the correct answer as nightmares about upcoming surgery indicate psychological distress commonly associated with fears, anxiety, and stress related to the treatment. Choices B, C, and D suggest positive emotions and proactive behaviors that are not typical signs of psychological distress in this context. Feeling more energetic, making future plans, and looking forward to treatment are generally positive indicators of coping and adjustment to the situation.

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