Nursing Elites

1. A nurse is assessing a client who is 1 day postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

• A. Urine output of 40 mL/hr.
• B. Heart rate of 88/min.
• C. Wound drainage of 25 mL in 24 hours.
• D. Abdominal distention and rigidity.

Correct answer: D

Rationale: Abdominal distention and rigidity may indicate a postoperative complication, such as bowel obstruction or peritonitis, and should be reported to the provider. While monitoring urine output, heart rate, and wound drainage are essential postoperative assessments, they are not as concerning as abdominal distention and rigidity, which could signal a more urgent issue requiring immediate attention.

2. Which lab value should be closely monitored for a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor potassium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.

3. When collecting a sputum specimen from a client with tuberculosis, what action should the nurse take?

• A. Obtain the specimen immediately upon the client waking up.
• B. Wait one day to collect the specimen if the client cannot provide sputum.
• C. Ask the client to provide 15 to 20 ml of sputum.
• D. Wear sterile gloves when collecting the specimen.

Correct answer: A

Rationale: The correct answer is to obtain the specimen immediately upon the client waking up. Collecting sputum early in the morning provides the best sample for tuberculosis testing. Option B is incorrect because waiting a day can decrease the accuracy of the specimen. Option C is incorrect as it does not specify the optimal timing for specimen collection. Option D is incorrect as sterile gloves should be worn for infection control but do not specifically relate to the timing of specimen collection.

4. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Weight loss.
• B. Bradycardia.
• C. Peripheral edema.
• D. Dry cough.

Correct answer: C

Rationale: The correct answer is C: Peripheral edema. In right-sided heart failure, the heart struggles to pump blood efficiently, leading to fluid backup in the body. This fluid retention commonly manifests as peripheral edema, causing swelling in the legs, ankles, and feet. Choices A, B, and D are incorrect. Weight loss is not typically associated with right-sided heart failure; bradycardia (slow heart rate) is more commonly seen in conditions like hypothyroidism or athletes, not specifically in right-sided heart failure; and a dry cough is more commonly associated with conditions like pneumonia or bronchitis, not typically with right-sided heart failure.

5. A nurse is providing teaching to a client who has been prescribed digoxin for heart failure. Which of the following instructions should the nurse include?

• A. Take this medication with meals.
• B. Check your pulse before taking this medication.
• C. Take this medication with an antacid to reduce stomach upset.
• D. Increase your potassium intake while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Check your pulse before taking this medication.' When a patient is prescribed digoxin, it is crucial to monitor their pulse rate because digoxin can cause bradycardia (slow heart rate) as a side effect. In contrast, choices A, C, and D are incorrect. Taking digoxin with meals is not necessary; it should be taken consistently at the same time every day. Taking digoxin with an antacid is not recommended as it can interfere with the absorption of the medication. While digoxin can cause hypokalemia (low potassium levels), patients should not increase their potassium intake without healthcare provider guidance to avoid potential complications.

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