Nursing Elites

1. A client is 2 hours postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate 88/min
• B. Capillary refill of 2 seconds
• C. Pain level of 8 on a scale of 0 to 10
• D. Temperature of 37.8°C (100°F)

Correct answer: C

Rationale: A pain level of 8 is high and may indicate inadequate pain control or complications following surgery. Monitoring and managing pain is crucial postoperatively to ensure patient comfort and prevent complications. A heart rate of 88/min, capillary refill of 2 seconds, and a temperature of 37.8°C (100°F) are within normal ranges and do not typically require immediate reporting unless in the context of other concerning signs or symptoms.

2. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

• A. Insert the catheter until urine flows, then advance 2.5 to 5 cm (1 to 2 in) further.
• B. Advance the catheter 7.5 to 10 cm (3 to 4 in) after urine begins to flow.
• C. Advance the catheter 17 to 22.5 cm (7 to 9 in) after urine begins to flow.
• D. Advance the catheter 5 to 7.5 cm (2 to 3 in) after urine begins to flow.

Correct answer: C

Rationale: When inserting an indwelling urinary catheter for a male client, it is crucial to advance the catheter 17 to 22.5 cm after urine begins to flow. This helps ensure proper placement in the male urethra, which is longer compared to females. Choice A is incorrect as advancing only 2.5 to 5 cm would not reach the correct placement in male clients. Choice B is incorrect as advancing 7.5 to 10 cm is insufficient to reach the appropriate location in male clients. Choice D is also incorrect as advancing 5 to 7.5 cm would likely not reach the desired placement in male clients.

3. A nurse is planning to administer a blood transfusion to a client. Which of the following should the nurse do to prevent an adverse transfusion reaction?

• A. Verify the client's blood type with the provider's prescription
• B. Ensure the client's consent for the transfusion is on file
• C. Administer a diuretic prior to starting the transfusion
• D. Check the client's temperature prior to the transfusion

Correct answer: A

Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.

4. A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid using aspirin for pain.
• B. I will consume dairy products to increase my calcium intake.
• C. I will drink 1.5 to 2 liters of fluid each day.
• D. I will need to limit my intake of fiber.

Correct answer: A

Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.

5. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

• A. Administer the immunization in the deltoid muscle
• B. Apply a cold compress to the injection site
• C. Apply pressure to the injection site for 5 minutes
• D. Administer a local anesthetic at the injection site

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

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