Nursing Elites

1. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

• A. Assess nail beds for color and refill
• B. Assess for postoperative arrhythmias
• C. Auscultate for pulmonary congestion
• D. Monitor equality of peripheral pulses

Correct answer: B

Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.

2. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?

• A. Check the protein level in urine
• B. Have the client turn to the left side
• C. Take the temperature
• D. Monitor the urine output

Correct answer: B

Rationale: In cases of preeclampsia with increasing blood pressure, the priority action for the nurse is to have the client turn to the left side. This position helps improve blood flow to the placenta and fetus, reducing the risk of complications. Checking the protein level in urine (Choice A) is important for assessing preeclampsia but not the immediate priority when blood pressure is increasing. Taking the temperature (Choice C) is not directly related to addressing increased blood pressure in preeclampsia. Monitoring urine output (Choice D) is essential but not the first action to take when blood pressure is rising.

3. A client with gastroesophageal reflux is receiving teaching from a nurse. Which statement by the client indicates a need for further teaching?

• A. I will avoid eating after supper.
• B. I can drink coffee throughout the day.
• C. I drink milk when I get heartburn.
• D. I should not eat foods made with chocolate.

Correct answer: B

Rationale: The correct answer is B. Drinking coffee throughout the day can aggravate gastroesophageal reflux symptoms. Choices A, C, and D are correct statements that can help manage gastroesophageal reflux by avoiding late-night eating, not consuming trigger foods like chocolate, and using milk for relief when experiencing heartburn.

4. A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?

• A. A heart rate of 90 beats per minute
• B. A blood pressure of 120/80 mm Hg
• C. A respiratory rate of 16 breaths per minute
• D. A temperature of 98.6 degrees Fahrenheit

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.

5. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?

• A. Change in libido, breast enlargement
• B. Sore throat, fever
• C. Abdominal pain, nausea, diarrhea
• D. Dsypnea, nasal congestion

Correct answer: B

Rationale: The correct answer is B: "Sore throat and fever." These symptoms can indicate a serious side effect of chlorpromazine and should be reported immediately. Choices A, C, and D are incorrect because they are not typically associated with adverse effects of chlorpromazine. Changes in libido and breast enlargement are not commonly linked to this medication. Abdominal pain, nausea, and diarrhea are more likely to be gastrointestinal side effects. Dyspnea and nasal congestion are not commonly reported adverse effects of chlorpromazine.

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