Nursing Elites

1. A nurse receives a report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reported that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first?

• A. Measure urinary output
• B. Assess for weakness or dizziness
• C. Increase IV fluids
• D. Check for vaginal bleeding

Correct answer: D

Rationale: Saturation of the perineal pad after a hysterectomy suggests excessive vaginal bleeding, which must be addressed immediately. Assessing for vaginal bleeding is the priority in this situation as it can lead to hypovolemic shock. Measuring urinary output, assessing for weakness or dizziness, and increasing IV fluids are important interventions but checking for vaginal bleeding takes precedence due to the risk of hemorrhage post-hysterectomy.

2. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

3. A young male client with an above-knee amputation (AKA) reports that his 'right foot is aching.' What is the most important intervention for the nurse to implement?

• A. Encourage discussion of feelings about the loss of his limb.
• B. Administer a prescription for gabapentin.
• C. Teach the client how to wrap the stump with an elastic bandage.
• D. Offer to assist the client to a quieter location to relax.

Correct answer: B

Rationale: The correct answer is B because gabapentin is prescribed to treat phantom limb pain, which is common in individuals with amputations. Option A is not the most important intervention at this time since the client is reporting physical pain, not emotional distress. Option C is not appropriate because the client is reporting aching in the foot, not the stump. Option D does not address the underlying issue of phantom limb pain that needs to be managed.

4. A client is admitted to the hospital with a diagnosis of septic shock. Which assessment finding indicates that the client's condition is deteriorating?

• A. Heart rate of 110 beats per minute
• B. Temperature of 99.5°F (37.5°C)
• C. Blood pressure of 88/52 mmHg
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which is a sign of worsening septic shock. Hypotension can lead to organ failure and requires immediate intervention. Elevated heart rate (choice A), mild fever (choice B), and slightly increased respiratory rate (choice D) are common in septic shock and may not necessarily indicate a deteriorating condition as much as hypotension does.

5. What symptoms suggest the dosage of levothyroxine sodium is too high in a 26-year-old client with simple goiter?

• A. Bradycardia and constipation.
• B. Palpitations and shortness of breath.
• C. Lethargy and lack of appetite.
• D. Muscle cramps and dry skin.

Correct answer: B

Rationale: The correct answer is B: Palpitations and shortness of breath. These symptoms suggest excessive thyroid hormone levels, indicating that the levothyroxine dose is too high. Bradycardia and constipation (choice A) are more indicative of hypothyroidism, which occurs when thyroid hormone levels are low. Lethargy and lack of appetite (choice C) are also common symptoms of hypothyroidism. Muscle cramps and dry skin (choice D) can be associated with various conditions but are not specific to a high dosage of levothyroxine.

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