Nursing Elites

1. When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?

• A. A halo of erythema on the surrounding skin
• B. Presence of serous drainage
• C. Edema around the wound
• D. Absence of granulation tissue

Correct answer: A

Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.

2. A healthcare professional is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the healthcare professional take?

• A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
• B. Recheck the pulse at the same site after 5 minutes.
• C. Measure the client’s blood pressure.
• D. Record the irregularity and continue with other vital signs.

Correct answer: A

Rationale: When an irregular pulse is detected, it is essential to count the apical pulse rate for a full minute to accurately determine the rhythm. This ensures a comprehensive assessment and helps in identifying any potential issues or abnormalities. Rechecking the pulse at the same site after 5 minutes (Choice B) may not provide an immediate understanding of the irregularity. Measuring the client's blood pressure (Choice C) is important but not directly related to addressing the irregular pulse. Recording the irregularity and continuing with other vital signs (Choice D) may overlook a potentially serious cardiac issue that requires immediate attention.

3. A parent is reviewing safety measures for an 8-month-old infant with a nurse. Which of the following statements by the parent indicates an understanding of safety for the infant?

• A. “My baby loved to play with the crib gym, but I took it out of the crib.”
• B. “I just bought a firm mattress so my baby will sleep better.”
• C. “My baby really likes sleeping on the fluffy pillow we just got.”
• D. “I put the baby’s car seat on the table after I put him in it.”

Correct answer: A

Rationale: Choice A is correct because removing the crib gym prevents potential safety hazards such as choking or entrapment. Choices B, C, and D are incorrect as they pose risks to the infant's safety. A firm mattress is recommended for infants to reduce the risk of suffocation. Soft mattresses and fluffy pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby's car seat on a table can lead to falls or other accidents.

4. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

• A. Swelling and redness in the affected leg
• B. Pain in the affected leg
• C. Warmth and tenderness in the affected leg
• D. A positive Homans' sign

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

5. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

• A. Liver damage
• B. Renal failure
• C. Gastric bleeding
• D. Heart attack

Correct answer: A

Rationale: Correct Answer: Large doses of acetaminophen can cause liver damage, which is a known adverse effect of the medication. Acetaminophen is metabolized in the liver, and excessive amounts can overwhelm the liver's ability to process it, leading to hepatotoxicity. Renal failure (Choice B) is not typically associated with acetaminophen use. Gastric bleeding (Choice C) is more commonly linked to nonsteroidal anti-inflammatory drugs (NSAIDs) rather than acetaminophen. Heart attack (Choice D) is not a recognized adverse effect of acetaminophen, which primarily affects the liver when taken in large amounts.

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