Nursing Elites

1. Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client’s dressing. Which additional assessment finding warrants immediate intervention by the nurse?

• A. Sore throat when swallowing
• B. Tongue deviation to the left
• C. Palpable temporal pulses
• D. Temperature of 99.2°F (37.3°C)

Correct answer: B

Rationale: Tongue deviation to the left is the correct answer. It could indicate a complication such as nerve injury or hematoma, which requires immediate attention. A sore throat when swallowing may be expected postoperatively but does not indicate an immediate complication. Palpable temporal pulses are a normal finding and do not require immediate intervention. A temperature of 99.2°F (37.3°C) is slightly elevated but does not suggest a critical issue related to the surgery.

2. The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?

• A. Current lab report indicates an Aptt at 1.5 times the client's control
• B. The client states that his right calf is aching and wants pain medication
• C. The spouse is assisting the client who is shaving with an electric razor
• D. Several bruised areas are noted on the client's upper extremities bilaterally

Correct answer: D

Rationale: The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.

3. When assessing a client's blood pressure and determining an auscultatory gap, which action should the nurse implement?

• A. Compare the palpated systolic blood pressure with the auscultated pressure
• B. Assess the client for lightheadedness upon standing
• C. Determine if an automated blood pressure reading is consistent with the manual reading
• D. Observe for changes in blood pressure between lying and sitting positions

Correct answer: A

Rationale: When an auscultatory gap is present, comparing the palpated systolic blood pressure with the auscultated pressure is crucial. This helps to accurately measure blood pressure and detect any discrepancies caused by the gap. Assessing for lightheadedness upon standing (choice B) is unrelated to addressing an auscultatory gap. Checking the consistency between automated and manual blood pressure readings (choice C) is important for validation but not specifically for managing an auscultatory gap. Observing blood pressure changes between lying and sitting positions (choice D) is relevant for orthostatic hypotension assessment but not for dealing with an auscultatory gap.

4. The client enters the room of a client with Parkinson’s disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?

• A. Demonstrate how to help the client move more efficiently
• B. Offer a PRN analgesic to reduce painful movement
• C. Affirm that the client should arise slowly from the chair
• D. Tell the UAP to assist the client in moving more quickly

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.

5. The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12-hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 ml, and voids twice. The dry diaper weighs 105 grams. Which computer documentation should the nurse enter in the infant’s record?

• A. Subtract vomitus from 120 ml Pedialyte, then document 95 ml oral intake.
• B. Compare the difference between the infant’s current weight and admission weight.
• C. Document on the flow sheet that the infant voided twice and vomited 25 ml.
• D. Calculate the difference in wet and dry diapers and document 80 ml urine.

Correct answer: C

Rationale: The correct answer is to document on the flow sheet that the infant voided twice and vomited 25 ml. This choice accurately reflects the need for accurate documentation of intake and output, essential for monitoring the infant's hydration status. Choice A is incorrect because the oral intake should not be calculated by subtracting vomitus from the oral intake. Choice B is incorrect because it does not address the specific documentation related to the infant's output. Choice D is incorrect as it focuses on calculating urine output based on diaper weight, which is not the primary concern in this scenario.

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