Nursing Elites

1. A nurse is reviewing the medical record of a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain of 1.4 kg (3 lb) in the past 2 weeks.
• B. Exophthalmos.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: A

Rationale: The correct answer is A. Weight gain can indicate myxedema, which is a symptom commonly seen in hypothyroidism. Exophthalmos (choice B) is actually a characteristic finding of hyperthyroidism, not hypothyroidism. Tachycardia (choice C) and heat intolerance (choice D) are also more indicative of hyperthyroidism rather than hypothyroidism.

2. A nurse is caring for a client who has severe hypertension and is receiving nitroprusside. What action should the nurse take?

• A. Administer oxygen and assess the client's response.
• B. Monitor blood pressure every 2 hours.
• C. Limit light exposure to the IV infusion.
• D. Attach an inline filter to the IV tubing.

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client receiving nitroprusside for severe hypertension is to limit light exposure to the IV infusion. Nitroprusside is light-sensitive, and exposure to light can lead to degradation of the medication, reducing its effectiveness. Administering oxygen (Choice A) may be necessary for some clients but is not directly related to the administration of nitroprusside. Monitoring blood pressure every 2 hours (Choice B) is a general nursing intervention for clients with hypertension but does not specifically address the administration of nitroprusside. Attaching an inline filter to the IV tubing (Choice D) is not necessary to address the specific concern of light exposure related to nitroprusside administration.

3. A client with a new diagnosis of type 2 diabetes mellitus is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will need to check my blood glucose level once a week.
• B. I will limit my carbohydrate intake to 50 grams per day.
• C. I should avoid eating foods high in protein.
• D. I should eat a snack if my blood glucose level is below 200 mg/dL.

Correct answer: D

Rationale: The correct answer is D. Clients with diabetes should eat a snack if their blood glucose level is below 70 mg/dL, not 200 mg/dL. Option A is incorrect because checking blood glucose levels once a week may not provide adequate monitoring for someone with diabetes. Option B is incorrect as a strict limit of 50 grams of carbohydrates per day may not be suitable for everyone and can vary based on individual needs. Option C is incorrect as it is important for clients with diabetes to have a balanced diet that includes protein in moderation.

4. What is the priority nursing assessment for a patient who has just returned from surgery?

• A. Monitor respiratory rate
• B. Monitor blood pressure
• C. Check the surgical site
• D. Monitor heart rate

Correct answer: A

Rationale: The correct answer is to monitor the patient's respiratory rate. This assessment is essential as it ensures that the patient is breathing adequately post-surgery. Maintaining a patent airway and adequate oxygenation are the top priorities in the immediate postoperative period. Monitoring blood pressure, checking the surgical site, or monitoring heart rate are important assessments but are not the priority immediately upon the patient's return from surgery.

5. A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?

• A. Increased oxygen saturation with exercise.
• B. Pursed-lip breathing with exertion.
• C. Productive cough with clear sputum.
• D. Clubbing of the fingers.

Correct answer: C

Rationale: The correct answer is C: 'Productive cough with clear sputum.' Clients with COPD often have a chronic productive cough with thick, often purulent sputum. This sputum can be white, yellow, green, or clear. Choices A, B, and D are incorrect. Oxygen saturation may decrease with exertion in COPD due to impaired gas exchange. Pursed-lip breathing is used to control dyspnea, not directly related to increased saturation with exercise. Clubbing of the fingers is typically seen in conditions such as cyanotic heart disease or lung cancer.

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