Nursing Elites

1. After surgery, a patient has decreased cardiac output. What is a likely observation by the nurse?

• A. Decreased urine output
• B. Increased urine output
• C. Flushing of the skin
• D. Hyperventilation

Correct answer: A

Rationale: A decrease in cardiac output can lead to decreased blood flow to the kidneys, resulting in decreased urine output. The kidneys rely on adequate blood supply to filter waste and produce urine. Therefore, a decreased urine output is a common observation when cardiac output is reduced. Choices B, C, and D are incorrect. Increased urine output is not typically associated with decreased cardiac output; flushing of the skin is more related to vasodilation, and hyperventilation is not directly linked to decreased cardiac output.

2. A client is scheduled for a colonoscopy. What instruction should the nurse provide to prepare the client for the procedure?

• A. Drink clear liquids for 24 hours before the procedure
• B. Take a laxative the morning of the procedure
• C. Eat a light meal before the procedure
• D. Avoid drinking fluids for 4 hours before the procedure

Correct answer: A

Rationale: The correct instruction for preparing a client for a colonoscopy is to drink clear liquids for 24 hours before the procedure. This step helps to ensure the bowel is adequately cleared for the colonoscopy, allowing for better visualization and examination of the colon.

3. A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client’s respiratory function?

• A. Arterial blood gases (ABGs)
• B. Complete blood count (CBC)
• C. Blood glucose levels
• D. Serum electrolyte levels

Correct answer: A

Rationale: Arterial blood gases (ABGs) are the most appropriate laboratory test to monitor respiratory function in a client with pneumonia. ABGs provide valuable information on oxygenation status, acid-base balance, and how well the lungs are exchanging gases. This information helps in assessing the effectiveness of ventilation and oxygenation, guiding treatment decisions, and evaluating the overall respiratory status of the client.

4. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

• A. Determine if the expected outcomes were realistic
• B. Obtain current client data to compare with expected outcomes
• C. Modify the nursing interventions to achieve the client’s goals
• D. Review related professional standards of care

Correct answer: A

Rationale: After reviewing the expected outcomes identified in the plan of care, the nurse's next step should be to determine if these outcomes were realistic. This assessment helps in understanding if the goals set were achievable and appropriate for the client's condition before proceeding to compare them with current client data or modifying nursing interventions. By verifying the realism of the expected outcomes, the nurse ensures a solid foundation for further evaluation and adjustment of the care plan. Option B is incorrect because obtaining current client data comes after assessing the realism of the expected outcomes. Option C is incorrect because modifying nursing interventions should be based on the assessment of the expected outcomes' realism. Option D is incorrect as reviewing professional standards of care is important but not the immediate next step after assessing the expected outcomes' realism.

5. When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?

• A. Position the client supine for a few minutes
• B. Assist the client to stand at the bedside
• C. Apply the blood pressure cuff securely
• D. Record the client’s pulse rate and rhythm

Correct answer: A

Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.

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