Nursing Elites

1. The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

• A. Respiratory rate of 16 breaths per minute
• B. Blood pressure of 120/80 mm Hg
• C. Temperature of 99.5 degrees Fahrenheit
• D. Heart rate of 80 beats per minute

Correct answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

2. A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?

• A. A heart rate of 72 beats per minute
• B. A blood pressure of 110/70 mm Hg
• C. Pupils equal and reactive to light
• D. Client reports headache

Correct answer: C

Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.

3. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

• A. Abdominal x-ray
• B. Auscultation
• C. Flushing tube with saline
• D. Aspiration for gastric contents

Correct answer: D

Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.

4. Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?

• A. Urinary incontinence
• B. Constipation
• C. Nystagmus
• D. Occult bleeding

Correct answer: D

Rationale: The correct answer is D: Occult bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are known to cause gastrointestinal side effects, including occult bleeding. Occult bleeding refers to bleeding in the gastrointestinal tract that may not be visible in the stool, leading to potential complications like anemia. Urinary incontinence (choice A) is not a common side effect of NSAIDs. Constipation (choice B) is also not a typical side effect associated with NSAIDs. Nystagmus (choice C) is an involuntary eye movement and is not a common side effect of NSAIDs. Therefore, the nurse should caution clients about the risk of occult bleeding when using NSAIDs for arthritis pain management.

5. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is:

• A. difference in the intake and output
• B. changes in the mucous membranes
• C. skin turgor
• D. weekly weight

Correct answer: D

Rationale: In a client with altered renal function, monitoring fluid balance is crucial. Weekly weight is the most accurate indicator of fluid balance during the visits as it reflects cumulative changes in the body's fluid status. Changes in intake and output (Choice A) can provide valuable information, but weekly weight is a more direct measure of overall fluid retention or loss. Changes in mucous membranes (Choice B) and skin turgor (Choice C) can be influenced by factors other than fluid balance, making them less reliable indicators in this context.

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