Nursing Elites

1. A nurse is assessing a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the dressing
• B. Heart rate of 88/min
• C. Urine output of 30 mL/hr
• D. Blood pressure of 110/70 mm Hg

Correct answer: C

Rationale: The correct answer is C because a urine output of 30 mL/hr indicates oliguria, which can be a sign of dehydration or kidney impairment postoperatively. This finding should be reported to the provider for further evaluation. Choices A, B, and D are within normal parameters for a client who is 2 days postoperative following abdominal surgery and do not raise immediate concerns. Serosanguineous drainage on the dressing is an expected finding in the early postoperative period, a heart rate of 88/min is within the normal range, and a blood pressure of 110/70 mm Hg is also within normal limits.

2. A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

• A. Weigh the client weekly to monitor for fluid retention.
• B. Monitor the client's blood glucose level every 6 hours.
• C. Change the TPN tubing every 72 hours.
• D. Flush the TPN line with sterile water before and after administration.

Correct answer: B

Rationale: The correct answer is B: Monitor the client's blood glucose level every 6 hours. When a client is on TPN, it is crucial to monitor their blood glucose levels frequently to prevent complications such as hyperglycemia or hypoglycemia. Weighing the client weekly to monitor for fluid retention (choice A) is important but not as critical as monitoring blood glucose levels. Changing the TPN tubing every 72 hours (choice C) is important for infection control but does not directly relate to the client's metabolic status. Flushing the TPN line with sterile water before and after administration (choice D) is not a standard practice and may introduce contaminants into the TPN solution.

3. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?

• A. Hgb 10 g/dL
• B. Platelets 300,000/mm³
• C. WBC count 12,000/mm³
• D. BUN 18 mg/dL

Correct answer: A

Rationale: The correct answer is A: Hgb 10 g/dL. A hemoglobin level of 10 g/dL is below the normal range for a pregnant client, indicating possible anemia, which is crucial to report during pregnancy to prevent complications for both the mother and the baby. Platelets, WBC count, and BUN levels within the listed values are generally within normal ranges for a pregnant individual at 28 weeks of gestation. Platelets play a role in blood clotting, WBC count helps in fighting infections, and BUN measures kidney function, all of which are typically expected to be within normal limits during pregnancy.

4. A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Respiratory rate of 10/min
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.

5. A nurse is preparing to administer medications to a client who has a nasogastric (NG) tube. Which of the following actions should the nurse take first?

• A. Check for tube placement.
• B. Flush the NG tube with 0.9% sodium chloride.
• C. Administer the medications as a bolus.
• D. Dissolve the medications in 30 mL of sterile water.

Correct answer: A

Rationale: The correct first action for the nurse to take when preparing to administer medications to a client with a nasogastric (NG) tube is to check for tube placement. This step is crucial to ensure that the NG tube is correctly positioned in the stomach and not in the respiratory tract, reducing the risk of aspiration. Flushing the NG tube with 0.9% sodium chloride, administering the medications as a bolus, or dissolving the medications in sterile water should only be done after confirming the proper placement of the NG tube. Therefore, options B, C, and D are incorrect as they precede the essential step of verifying tube placement.

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