Nursing Elites

1. What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?

• A. Maintain adequate hydration
• B. Assist the client to turn, deep breathe, and cough
• C. Ambulate the client within 12 hours
• D. Splint the incision

Correct answer: B

Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.

2. A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?

• A. Magnesium
• B. Calcium
• C. Chloride
• D. Potassium

Correct answer: C

Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.

3. The client is being taught to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

• A. Three apricots
• B. Medium banana
• C. Naval orange
• D. Baked potato

Correct answer: D

Rationale: The correct answer is D. A baked potato is high in potassium and helps prevent digitalis toxicity by maintaining adequate potassium levels. While choices A, B, and C all contain some potassium, a baked potato is a more concentrated source of potassium compared to three apricots, a medium banana, or a naval orange. Therefore, the client should choose a baked potato to better meet the dietary needs for preventing digitalis toxicity.

4. A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?

• A. Decreased deep-tendon reflexes
• B. Skeletal muscle weakness
• C. Hypoactive bowel sounds
• D. Tingling of the lips

Correct answer: D

Rationale: The correct answer is D, tingling of the lips (perioral tingling). This is a common symptom of hypocalcemia due to increased neuromuscular excitability. Choice A, decreased deep-tendon reflexes, is more indicative of hypercalcemia. Choice B, skeletal muscle weakness, is associated with hypokalemia. Choice C, hypoactive bowel sounds, is not a typical finding in hypocalcemia.

5. A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?

• A. Risk for injury related to exophthalmos
• B. Impaired social interaction related to emotional lability
• C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
• D. Activity intolerance related to fatigue

Correct answer: D

Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.

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