Nursing Elites

1. A client is post-operative day 1 and reports a sudden increase in blood-tinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?

• A. Send the client back to surgery
• B. Assess the wound for signs of dehiscence
• C. Call the provider immediately
• D. Prepare to culture the wound

Correct answer: B

Rationale:

2. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

• A. The client refused her pain medication this morning and is doing physical therapy.
• B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
• C. The client reports intermittent flatus and minor abdominal discomfort.
• D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

3. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

• A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
• B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
• C. The UAP carefully empties the indwelling catheter bag
• D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

4. What client is a susceptible host most at risk for infection?

• A. A client with leukemia
• B. A hospitalized 35-year-old-client
• C. A child who is immunized
• D. A 60-year-old client

Correct answer: A

Rationale:

5. What is an example of a client's primary defense to infection?

• A. Intact skin
• B. Inflammation
• C. Phagocytosis
• D. Fever

Correct answer: A

Rationale:

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