Nursing Elites

1. When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency?

• A. Reports of leg cramping at rest
• B. Family history of heart disease
• C. Current use of beta-blockers
• D. History of intermittent claudication

Correct answer: D

Rationale: Corrected Rationale: Intermittent claudication, or pain in the legs while walking that is relieved by rest, is a classic symptom of peripheral arterial insufficiency. Other factors such as a family history or medication use may contribute to cardiovascular health, but claudication is the most specific indicator. Leg cramping at rest is more indicative of conditions like peripheral neuropathy or deep vein thrombosis. Family history of heart disease and current use of beta-blockers are relevant to overall cardiovascular health, but they are not as directly related to chronic peripheral arterial insufficiency as intermittent claudication.

2. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?

• A. Decreased heart rate
• B. Increased appetite
• C. Cold intolerance
• D. Weight gain

Correct answer: B

Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.

3. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Recent lab tests show decreased serum magnesium. What nursing action is most important?

• A. Observe rhythm on telemetry monitor.
• B. Check for visual difficulties.
• C. Assess for hip and hand joint pain.
• D. Note the most recent hemoglobin level.

Correct answer: A

Rationale: Magnesium plays a crucial role in maintaining normal cardiac rhythms, particularly in patients with cardiac conditions. Abnormal levels can lead to arrhythmias, which is why continuous monitoring of the heart's electrical activity is important. Magnesium's effect on neuromuscular and cardiac function makes it essential to monitor its levels, and any discrepancies can impact treatment decisions. Checking for visual difficulties (choice B) may be important in MG but is not the priority in the context of decreased serum magnesium. Assessing for hip and hand joint pain (choice C) is not directly related to the issue of decreased serum magnesium. Noting the most recent hemoglobin level (choice D) is not the priority in this situation compared to monitoring the cardiac rhythm due to low magnesium levels.

4. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

• A. Assign an RN to supervise a nursing assistant for skin care
• B. Assign a nursing assistant to help the client with self-care activities
• C. Delegate complete care to an unlicensed assistive personnel
• D. Supervise a nursing assistant for skin care

Correct answer: D

Rationale: In this scenario, the best care assignment for the client with a skin tear and hematoma is to supervise a nursing assistant for skin care. This ensures proper wound care while utilizing the skills of the nursing assistant effectively. Assigning an RN to supervise the nursing assistant is appropriate as it provides the necessary expertise for wound care supervision. Delegating complete care to an unlicensed assistive personnel may not be suitable for a client with specific wound care needs. Helping the client with self-care activities may not directly address the urgent need for proper wound care in this situation.

5. The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?

• A. Heart rate of 88 beats per minute
• B. Blood pressure of 100/60
• C. Oxygen saturation of 94%
• D. Respiratory rate of 16

Correct answer: C

Rationale: The correct answer is C. Oxygen saturation levels below 95% indicate hypoxia and require immediate intervention. A heart rate of 88 beats per minute, a blood pressure of 100/60, and a respiratory rate of 16 are within normal ranges and do not require immediate intervention. Oxygen saturation is a critical parameter reflecting the client's oxygenation status.

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