Nursing Elites

1. A nurse is assessing a client who has a history of urinary incontinence. Which of the following findings should the nurse report to the provider?

• A. Urine output of 50 mL in 2 hours
• B. Presence of an indwelling urinary catheter
• C. Frequent urination at night
• D. Dark-colored urine

Correct answer: D

Rationale: The correct answer is D, dark-colored urine. Dark-colored urine can indicate various issues such as dehydration, liver problems, or blood in the urine, which could be concerning and require further evaluation by the provider. Choices A, B, and C are not necessarily findings that would need immediate reporting to the provider. A urine output of 50 mL in 2 hours might be low but could be influenced by various factors and might not always require immediate action. The presence of an indwelling urinary catheter is a known history and not a new finding. Frequent urination at night could be a symptom related to various conditions but may not be an urgent concern unless accompanied by other significant symptoms.

2. A nurse is caring for a client who is postoperative following a hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

• A. Place a pillow between the client's legs.
• B. Place the client in a high Fowler's position.
• C. Maintain the client in a side-lying position.
• D. Keep the client's legs elevated.

Correct answer: A

Rationale: Placing a pillow between the client's legs is the correct action to prevent dislocation of the prosthesis after hip arthroplasty. This positioning helps maintain proper alignment and stability of the hip joint, reducing the risk of dislocation. Placing the client in a high Fowler's position (choice B) is not recommended after hip arthroplasty as it may strain the hip joint. Maintaining the client in a side-lying position (choice C) or keeping the client's legs elevated (choice D) does not provide the same level of support and alignment as placing a pillow between the legs.

3. A client with Parkinson's disease is receiving physical therapy. Which statement by the client indicates the need for a referral to physical therapy?

• A. I have been experiencing more tremors in my left arm than before
• B. I noticed that I am having a harder time holding onto my toothbrush
• C. Lately, I feel like my feet are freezing up, as they are stuck to the ground
• D. Sometimes, I feel I am making a chewing motion when I'm not eating

Correct answer: C

Rationale: The correct answer is C because freezing of feet while walking is a sign of impaired mobility, indicating the need for physical therapy in clients with Parkinson's disease. Choices A, B, and D are symptoms commonly associated with Parkinson's disease but do not specifically indicate the need for immediate referral to physical therapy.

4. Which of the following lab values should the nurse monitor for a patient receiving heparin therapy?

• A. Monitor platelet count
• B. Monitor PT/INR
• C. Monitor aPTT
• D. Monitor CBC

Correct answer: C

Rationale: The correct answer is to monitor aPTT for a patient receiving heparin therapy. The activated partial thromboplastin time (aPTT) is used to assess and adjust heparin dosage to ensure the patient is within the therapeutic range for anticoagulation. Monitoring the aPTT helps in preventing both clotting and bleeding complications. Platelet count (Choice A) is important to monitor for patients receiving antiplatelet therapy, not heparin. PT/INR (Choice B) is typically monitored for patients on warfarin therapy, not heparin. Monitoring the complete blood count (CBC) (Choice D) is essential for various conditions but is not specific to monitoring heparin therapy.

5. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent constipation, straining, and subsequent bleeding, which is crucial for clients with thrombocytopenia. Encouraging the client to floss daily (Choice A) is important for oral hygiene but not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems to reduce the risk of foodborne illnesses but is not directly related to thrombocytopenia management.

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