Nursing Elites

1. A nurse is assessing a client who has a new diagnosis of heart failure. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Serum potassium level of 4.0 mEq/L
• C. Weight gain of 2 kg (4.4 lb) in 2 days
• D. Heart rate of 76/min

Correct answer: C

Rationale: A weight gain of 2 kg (4.4 lb) in 2 days can indicate fluid retention, which is a sign of worsening heart failure and should be reported. This rapid weight gain suggests a fluid overload, putting the client at risk for complications. A heart rate of 90/min is slightly elevated but not as concerning as a sudden significant weight gain. The serum potassium level of 4.0 mEq/L is within the normal range and does not directly indicate worsening heart failure. A heart rate of 76/min is within the normal range and does not raise immediate concerns related to heart failure.

2. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella roster. Which of the following information should the nurse include?

• A. Children who have varicella are contagious until vesicles are crusted
• B. Children who have varicella should receive the herpes zoster vaccination
• C. Children who have varicella should be placed in droplet precautions
• D. Children who have varicella are contagious 4 days before the first vesicle eruption

Correct answer: A

Rationale: The correct answer is A. Children with varicella are contagious until the vesicles crust over, which is important for preventing transmission. Choice B is incorrect as varicella and herpes zoster are caused by different viruses, so the varicella vaccine is given to prevent varicella, not herpes zoster. Choice C is incorrect because varicella is primarily spread through respiratory secretions, so airborne precautions are recommended, not droplet precautions. Choice D is incorrect as children with varicella are contagious even before the first vesicle eruption, not just 4 days before.

3. What is the best way to manage a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Apply compression stockings
• C. Encourage ambulation
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer anticoagulants. Administering anticoagulants is crucial in managing patients with suspected DVT as it helps prevent further clot formation and reduces the risk of complications like pulmonary embolism. Choice B, applying compression stockings, is more focused on preventing DVT in high-risk patients rather than managing an established case. Encouraging ambulation, choice C, is beneficial in the prevention of DVT but is not the primary management for suspected cases. Monitoring oxygen saturation, choice D, is important in overall patient care but is not the primary intervention for suspected DVT.

4. A nurse is caring for a client who is 12 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Respiratory rate of 16/min.
• C. Heart rate of 90/min.
• D. WBC count of 15,000/mm3.

Correct answer: D

Rationale: A WBC count of 15,000/mm3 is elevated, which may indicate infection, a common concern postoperatively. An elevated WBC count suggests the body is fighting an infection, and prompt reporting to the provider is essential for further evaluation and treatment. Serosanguineous drainage on the surgical dressing is expected in the immediate postoperative period, respiratory rate of 16/min is within the normal range, and a heart rate of 90/min is also within an acceptable range postoperatively. Therefore, these findings do not raise immediate concerns that necessitate reporting to the provider.

5. A nurse is providing discharge teaching to a client who has a wound infection. Which of the following information should the nurse include about home care?

• A. Soak the wound in warm water every day
• B. Use hydrogen peroxide to clean the wound
• C. Apply a cold compress to the wound
• D. Keep the wound covered with a dry dressing

Correct answer: D

Rationale: The correct answer is D: 'Keep the wound covered with a dry dressing.' When providing care for a wound infection, it is essential to keep the wound covered with a dry dressing to prevent further contamination and promote healing. Soaking the wound in warm water (choice A) can introduce moisture and increase the risk of infection. Using hydrogen peroxide (choice B) can be too harsh and may slow down the healing process by damaging healthy tissue. Applying a cold compress (choice C) is not typically recommended for wound infections, as it may not provide the necessary environment for healing.

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