Nursing Elites

1. The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Complaint of headaches and stiff neck.
• B. Complaint of dizziness and nausea.
• C. Increased pain at the puncture site.
• D. Mild redness around the puncture site.

Correct answer: A

Rationale: The correct answer is A: Complaint of headaches and stiff neck. Headaches and stiff neck following a myelogram may indicate a cerebrospinal fluid (CSF) leak or other complications that require prompt medical attention. Reporting this finding immediately is crucial to prevent further complications. Choices B, C, and D are incorrect because while they may warrant monitoring and intervention, they are not as indicative of a potentially serious complication as the symptoms described in choice A.

2. The nurse is caring for a client who is postoperative following a thyroidectomy. Which laboratory value should be monitored closely?

• A. Serum calcium of 8.5 mg/dL
• B. Serum sodium of 136 mEq/L
• C. Serum potassium of 3.0 mEq/L
• D. Serum chloride of 102 mEq/L

Correct answer: C

Rationale: A serum potassium level of 3.0 mEq/L should be monitored closely in a client who is postoperative following a thyroidectomy to detect any electrolyte imbalances. After a thyroidectomy, there is a risk of hypokalemia due to the effects of anesthesia, stress response, and the surgical procedure itself. Monitoring serum potassium levels is crucial as hypokalemia can lead to cardiac arrhythmias and muscle weakness. Serum calcium, sodium, and chloride levels are important but not the primary focus following a thyroidectomy, making them incorrect choices.

3. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

• A. Prepare the client for an emergency cesarean birth
• B. Encourage the client to move to a hands-and-knees position
• C. Assist the client to sharply flex her thighs up against the abdomen
• D. Lower the head of the bed and apply suprapubic pressure

Correct answer: C

Rationale: In cases of shoulder dystocia, the priority intervention is to assist the client in sharply flexing her thighs up against the abdomen (McRoberts maneuver). This action helps to widen the pelvic outlet. Encouraging the client to move to a hands-and-knees position may also be beneficial in some cases but is not the first-line intervention. Preparing for an emergency cesarean birth and applying suprapubic pressure are not appropriate initial interventions for shoulder dystocia.

4. The nurse is caring for a client with chronic kidney disease (CKD). Which laboratory value should be reported to the healthcare provider immediately?

• A. Serum creatinine of 2.0 mg/dl
• B. Hemoglobin of 10 g/dl
• C. Potassium of 6.5 mEq/L
• D. Blood glucose of 150 mg/dl

Correct answer: C

Rationale: The correct answer is C. A potassium level of 6.5 mEq/L is dangerously high, a condition known as hyperkalemia, and requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, making it crucial to notify the healthcare provider promptly. Choices A, B, and D do not indicate immediate life-threatening conditions. Elevated serum creatinine levels are expected in CKD, a hemoglobin level of 10 g/dl is within a reasonable range, and a blood glucose level of 150 mg/dl is not acutely concerning in this context.

5. The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?

• A. Slight difficulty swallowing
• B. Hoarse voice
• C. Positive Chvostek's sign
• D. Pain at the incision site

Correct answer: C

Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.

Similar Questions