Nursing Elites

1. What is the most important assessment for a patient post-surgery?

• A. Monitor vital signs
• B. Check surgical site for bleeding
• C. Check for abnormal breath sounds
• D. Check skin color

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs provide crucial information about a patient's physiological status, helping detect early signs of complications such as shock, bleeding, or infection. Checking the surgical site for bleeding is important but falls secondary to monitoring vital signs, which give a broader overview of the patient's condition. Checking for abnormal breath sounds and skin color are also important assessments, but they are not as immediate and general as monitoring vital signs in detecting various post-surgical complications.

2. A nurse is reviewing the medical record of a client who has a prescription for spironolactone. Which of the following findings should the nurse report to the provider?

• A. Potassium 5.0 mEq/L
• B. Blood pressure 136/84 mm Hg
• C. Sodium 140 mEq/L
• D. Calcium 9.5 mg/dL

Correct answer: A

Rationale: A potassium level of 5.0 mEq/L is at the upper limit of normal and should be monitored closely in clients taking spironolactone, which is potassium-sparing. Elevated potassium levels can lead to hyperkalemia, especially in individuals on potassium-sparing diuretics like spironolactone. Monitoring and reporting high potassium levels are crucial to prevent potential complications such as cardiac arrhythmias. Blood pressure (choice B), sodium level (choice C), and calcium level (choice D) are not directly related to the use of spironolactone and do not require immediate reporting in this scenario.

3. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is the best predictor of future violence as individuals who have a history of violent behavior are more likely to engage in violent acts in the future. While experiencing delusions and being male may contribute to an increased risk of violence in certain situations, they are not as strong predictors as a history of violence. Similarly, having a history of being in prison may indicate a higher likelihood of violence, but it is not as directly linked to future violent behavior as previous violent actions.

4. What is the best nursing action for a patient experiencing shortness of breath?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Reposition the patient
• D. Provide IV fluids

Correct answer: A

Rationale: Administering oxygen is the best nursing action for a patient experiencing shortness of breath as it helps alleviate the symptoms and improve oxygenation. Providing oxygen addresses the primary issue of inadequate oxygen levels in the body, which can be a life-threatening situation. Administering bronchodilators (choice B) may be appropriate for specific respiratory conditions like asthma but is not the initial intervention for all causes of shortness of breath. Repositioning the patient (choice C) can sometimes help improve breathing, but in a patient experiencing significant shortness of breath, immediate oxygen therapy is crucial. Providing IV fluids (choice D) is not indicated as the first-line intervention for shortness of breath unless there is a specific underlying cause such as dehydration.

5. A nurse is caring for a client who has a fecal impaction. Which action should the nurse take when digitally evacuating the stool?

• A. Insert a lubricated gloved finger and advance along the rectal wall
• B. Apply lubricant and stimulate peristalsis
• C. Apply pressure to the abdomen to assist with removal
• D. Increase fluid intake before the procedure

Correct answer: A

Rationale: The correct action when digitally evacuating a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and effectively dislodge the impacted stool. Choice B, applying lubricant and stimulating peristalsis, is incorrect as it does not directly address the evacuation of the impacted stool. Choice C, applying pressure to the abdomen, is inappropriate and may cause discomfort or harm to the client. Choice D, increasing fluid intake before the procedure, is not directly related to the immediate evacuation of the fecal impaction.

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