Nursing Elites

1. After receiving a report, the nurse receives the laboratory values for four clients. Which client requires the nurse’s immediate intervention? The client who is...

• A. Short of breath after a shower and has a hemoglobin of 8 grams
• B. Bleeding from a finger stick and has a prothrombin time of 30 seconds
• C. Febrile and has a WBC count of 14,000/mm3
• D. Trembling and has a glucose level of 50 mg/dL

Correct answer: D

Rationale: A glucose level of 50 mg/dL is indicative of hypoglycemia, which requires immediate intervention to prevent further complications. Hypoglycemia can lead to serious consequences such as altered mental status, seizures, and even coma if not promptly addressed. The other options do not present immediate life-threatening conditions that require urgent intervention. Shortness of breath with a hemoglobin of 8 grams may indicate anemia but does not require immediate intervention. Bleeding from a finger stick with a prothrombin time of 30 seconds may suggest clotting issues, which are important but not as immediately critical as hypoglycemia. Being febrile with an elevated WBC count could indicate infection, which is concerning but not as urgently critical as hypoglycemia.

2. After a 26-year-old gravida 4, para 0 experienced a spontaneous abortion at 9 weeks gestation, how should the nurse intervene after observing the client crying softly one hour post dilation and curettage (D&C)?

• A. Offer to call the social worker to discuss the possibility of adoption
• B. Reassure the client that the infertility specialist can help
• C. Express sorrow for the client's grief and offer to sit with her
• D. Chart the vital signs and amount of vaginal bleeding

Correct answer: C

Rationale: After a traumatic experience like a spontaneous abortion, it is crucial for the nurse to provide emotional support. Expressing sorrow for the client's grief and offering to sit with her demonstrates empathy and allows the client to process her emotions. Options A and B focus on future possibilities and medical interventions, which may not be immediately appropriate. Option D, while important for monitoring the client's physical status, does not address the client's emotional needs at that moment.

3. The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?

• A. I will change my colostomy bag every day.
• B. I should eat a low-fiber diet.
• C. I need to inspect the stoma daily for color and swelling.
• D. I can skip my colostomy care if I feel well.

Correct answer: C

Rationale: The correct answer is C because inspecting the stoma daily is crucial in identifying any early signs of complications or infections. Choice A is incorrect because changing the colostomy bag daily is not necessary unless there is a specific reason to do so. Choice B is incorrect as a low-fiber diet is not usually recommended for colostomy care. Choice D is incorrect because colostomy care should be performed regularly regardless of how the client feels.

4. A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?

• A. Increase intake of green leafy vegetables
• B. Maintain a consistent intake of vitamin K-rich foods
• C. Avoid all foods containing vitamin K
• D. Consume a high-protein diet

Correct answer: B

Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.

5. The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?

• A. Hoarseness of the voice
• B. Slight swelling at the incision site
• C. Tingling around the mouth
• D. Mild fever

Correct answer: C

Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.

Similar Questions