Nursing Elites

1. The nurse is caring for a client who is postoperative following a thyroidectomy. Which finding requires immediate intervention?

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

Correct answer: C

Rationale: A positive Chvostek's sign indicates hypocalcemia, a common complication following thyroidectomy due to inadvertent parathyroid gland injury. Immediate intervention is needed to prevent severe hypocalcemia symptoms like tetany, seizures, and laryngospasm. Hoarse voice and slight difficulty swallowing are expected post-thyroidectomy and do not require immediate intervention. Pain at the incision site is common postoperatively and can be managed with appropriate pain relief measures.

2. A client who is post-op day 1 after abdominal surgery reports pain at the incision site. The nurse notes the presence of a small amount of serosanguineous drainage. What is the most appropriate nursing action?

• A. Apply a sterile dressing to the incision.
• B. Reinforce the dressing and document the findings.
• C. Remove the dressing and assess the incision site.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: The correct answer is to reinforce the dressing and document the findings. It is important to monitor the incision site closely after surgery, especially when there is a small amount of serosanguineous drainage. Reinforcing the dressing helps maintain cleanliness and pressure on the wound. Documenting the findings is crucial for tracking the client's progress and alerting healthcare providers if necessary. Applying a sterile dressing (Choice A) may not be needed if the current dressing is intact. Removing the dressing (Choice C) can increase the risk of contamination. Notifying the healthcare provider (Choice D) is not the first step for minor drainage on post-op day 1.

3. A client is admitted with a diagnosis of pneumonia and is receiving IV antibiotics. Which assessment finding indicates that the treatment is effective?

• A. Client reports less chest pain.
• B. Client's white blood cell count is decreasing.
• C. Client has a decreased respiratory rate.
• D. Client has clear breath sounds.

Correct answer: D

Rationale: The correct answer is D. Clear breath sounds indicate that the pneumonia is resolving and the treatment is effective. Breath sounds are often muffled or crackling in pneumonia due to the presence of fluid or inflammation in the lungs. Clear breath sounds suggest that the air is moving freely through the lungs, indicating improvement. Choices A, B, and C are less specific indicators of pneumonia resolution. While less chest pain and a decreasing white blood cell count can be positive signs, they are not as direct in indicating the effectiveness of pneumonia treatment as the presence of clear breath sounds. A decreased respiratory rate could be seen in various conditions and may not solely indicate the resolution of pneumonia.

4. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

• A. Blood pressure 90/76 mm Hg.
• B. Heart rate of 85 bpm.
• C. Respiratory rate of 20 breaths/minute.
• D. Temperature of 99°F (37.2°C).

Correct answer: A

Rationale: Clonidine can lower blood pressure, so a BP of 90/76 mm Hg may indicate that it is unsafe to administer another dose. In this situation, the low blood pressure reading indicates that the client is already experiencing hypotension, which is a common side effect of clonidine. Administering more clonidine could further lower the blood pressure, leading to potential complications. The heart rate, respiratory rate, and temperature are within normal limits and do not serve as contraindications for administering clonidine in this scenario.

5. The nurse is assessing a client with left-sided heart failure. Which finding requires immediate intervention?

• A. Shortness of breath
• B. Jugular venous distention
• C. Crackles in the lungs
• D. Peripheral edema

Correct answer: C

Rationale: Crackles in the lungs indicate pulmonary congestion in a client with left-sided heart failure and require immediate intervention to prevent respiratory failure. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potentially respiratory distress. Shortness of breath, jugular venous distention, and peripheral edema are common manifestations of heart failure but do not directly indicate acute respiratory compromise like crackles in the lungs do.

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