Nursing Elites

1. The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?

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

Correct answer: A

Rationale: Corrected Rationale: Monitoring calcium levels is crucial post-thyroid surgery to detect hypocalcemia, a common complication due to injury or removal of the parathyroid glands. Monitoring sodium, chloride, or potassium levels is not as vital in the immediate post-thyroid surgery period.

2. The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide?

• A. Destroy any hidden supplies of alcohol she has at home so she has to stay sober
• B. When she drinks, communicate how disruptive her behaviors are and the burden they inflict on the family
• C. Make her responsible for the consequences of her drinking behaviors
• D. Include her in family activities whether she is drinking or sober

Correct answer: C

Rationale: The best approach for the nurse to suggest is to make the woman responsible for the consequences of her drinking behaviors. By holding her accountable, she is more likely to recognize the impact of her actions and potentially initiate change. Destroying hidden alcohol supplies (Choice A) might lead to conflict and further secretive behavior. Simply communicating the disruptions caused by her drinking (Choice B) may not effectively address the issue. Including her in family activities regardless of her drinking status (Choice D) could enable the behavior and not address the underlying problem.

3. Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?

• A. Complaints of an occipital headache
• B. A palpable dorsal pedis pulse bilaterally
• C. Complaints of shortness of breath on exertion
• D. A blood pressure of 160/90

Correct answer: C

Rationale: The correct answer is C, complaints of shortness of breath on exertion. This symptom is indicative of heart failure, a common cardiac complication of arterial hypertension. Shortness of breath on exertion is often due to the heart's inability to pump effectively, leading to fluid buildup in the lungs. Choices A, B, and D are incorrect because complaints of an occipital headache, a palpable dorsal pedis pulse bilaterally, and a blood pressure of 160/90 do not specifically indicate a cardiac complication in a client with arterial hypertension.

4. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?

• A. Heparin prevents future clot formation, but your risk of bleeding needs to be monitored closely
• B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
• C. Let me contact your surgeon and find out if Heparin IV therapy can be administered to you at home
• D. Why are you so anxious to leave the hospital when you know you are not well enough yet?

Correct answer: A

Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.

5. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

• A. The depth of tissue destruction is minor
• B. Pain is interrupted due to nerve compression
• C. The full thickness burn has destroyed the nerves
• D. Second-degree burns are not usually painful

Correct answer: C

Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.

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