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 nurse is reinforcing teaching about foods that enhance iron absorption when consumed with nonheme iron with a client who has iron deficiency anemia. Which of the following foods should the nurse include in the teaching?

• A. Tomato juice
• B. Tea
• C. Milk
• D. Dried beans

Correct answer: A

Rationale: The correct answer is A, Tomato juice. Tomato juice is high in vitamin C, which enhances the absorption of nonheme iron from foods. Vitamin C helps convert nonheme iron to a form that is easier for the body to absorb. Tea (choice B) contains tannins that can inhibit iron absorption. Milk (choice C) contains calcium, which can interfere with iron absorption. Dried beans (choice D) are a good source of nonheme iron but do not enhance iron absorption when consumed with nonheme iron.

3. During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?

• A. Breath sounds are auscultated bilaterally
• B. Mist is visible in the T-Piece
• C. Pulse oximetry of 88%
• D. Client is unable to speak

Correct answer: C

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.

4. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?

• A. Nausea and vomiting
• B. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
• C. Diffuse macular rash
• D. Muscle tenderness

Correct answer: B

Rationale: A high fever, such as 103 degrees Fahrenheit (39.5 degrees Celsius), in a client with infective endocarditis indicates that the infection may not be responding to the antibiotics and requires immediate medical evaluation. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically associated with the ineffectiveness of antibiotic therapy in infective endocarditis.

5. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?

• A. Bleeding time
• B. Hemoglobin and hematocrit
• C. White blood cells
• D. Platelets

Correct answer: B

Rationale: Corrected Hemoglobin and hematocrit levels should be monitored closely after blood transfusions to assess the effectiveness and identify any complications. Monitoring hemoglobin and hematocrit levels helps evaluate the patient's oxygen-carrying capacity and blood volume. While platelets are crucial for clotting, they are not typically affected immediately after a blood transfusion. White blood cell count monitoring is more relevant in assessing infection or immune response, not directly related to a blood transfusion. Bleeding time measures platelet function, which is not the primary concern immediately after a blood transfusion.

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