Nursing Elites

1. The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?

• A. Client reports dizziness
• B. Client has a drop in blood pressure
• C. Client experiences mild nausea
• D. Client reports dry mouth

Correct answer: B

Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.

2. A client with severe dehydration is admitted to the hospital. Which assessment finding indicates that the client's condition is improving?

• A. The client reports feeling less thirsty
• B. Urine output increases to 40 mL/hour
• C. Heart rate decreases from 120 to 110 beats per minute
• D. Skin turgor returns to normal

Correct answer: B

Rationale: An increase in urine output is a reliable indicator that the client's hydration status is improving. This reflects adequate fluid replacement and improved kidney function. Choice A is subjective and may not always indicate improved hydration. Choice C, while a positive sign, may be influenced by other factors such as medications or pain. Choice D, skin turgor returning to normal, is a delayed indicator of hydration status and may take time to improve even after hydration is initiated.

3. An adult client with a broken femur reports muscle spasms. What action should the nurse implement while awaiting surgery?

• A. Check the client's most recent electrolyte levels.
• B. Administer a PRN dose of muscle relaxant.
• C. Reduce the weight on the traction device.
• D. Encourage oral fluid intake to relieve muscle tension.

Correct answer: D

Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.

4. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. What action should the nurse take when finding the radiation implant in the bed?

• A. Call radiation therapy for assistance
• B. Place the implant in a lead container using long-handled forceps
• C. Leave the implant in the bed and notify the provider
• D. Dispose of the implant in the nearest sharps container

Correct answer: B

Rationale: The correct action for the nurse to take when finding the radiation implant in the bed is to use long-handled forceps to place the implant in a lead container. This procedure is crucial in reducing radiation exposure to both the patient and healthcare providers. Calling radiation therapy for assistance (Choice A) may delay the immediate need for safe handling of the implant. Leaving the implant in the bed and notifying the provider (Choice C) is unsafe and can lead to increased radiation exposure. Disposing of the implant in a sharps container (Choice D) is incorrect as the implant should be placed in a lead container, not a sharps container, to contain the radiation.

5. An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication?

• A. The client has been taking multiple medications
• B. The client is experiencing increasing confusion
• C. The client's vital signs are stable
• D. The client fell at home and has sustained bruises

Correct answer: B

Rationale: When utilizing the SBAR communication method, the nurse should prioritize reporting the client's increasing confusion to the healthcare provider first. Sudden onset of confusion in an older adult following a fall can indicate serious underlying conditions like a head injury, medication reaction, or infection. Addressing the confusion as the primary concern ensures prompt assessment and appropriate treatment. Choices A, C, and D are not as urgent as the client's increasing confusion and may be addressed after ensuring immediate attention to the potential critical issue.

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