Nursing Elites

1. A nurse is assessing a client who is 48 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. Temperature of 37.8°C (100°F).
• C. Urine output of 75 mL in the past 4 hours.
• D. WBC count of 15,000/mm³.

Correct answer: D

Rationale: The correct answer is D. An elevated WBC count can indicate a potential infection, especially in a postoperative client. This finding should be reported to the provider for further evaluation and management. Choices A, B, and C are common occurrences in postoperative clients and may not necessarily indicate a severe issue. Serosanguineous drainage on the surgical dressing is a normal finding in the immediate postoperative period. A temperature of 37.8°C (100°F) can be a mild fever, which is common postoperatively due to the body's response to tissue injury. Urine output of 75 mL in the past 4 hours may be within normal limits for a postoperative client, especially if they are still recovering from anesthesia.

2. A client with a new diagnosis of hypertension is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will check my blood pressure at least once a week.
• B. I will avoid eating foods high in potassium.
• C. I should exercise for 30 minutes at least 5 days a week.
• D. I will take my medication only when I feel dizzy.

Correct answer: C

Rationale: The correct answer is C. Regular exercise is an essential component in managing hypertension. Exercising for at least 30 minutes a day, at least 5 days a week, can help control blood pressure. Checking blood pressure regularly (choice A) is important, but not as indicative of understanding the teaching as the commitment to regular exercise. Avoiding foods high in potassium (choice B) is not a typical recommendation for managing hypertension. Taking medication only when feeling dizzy (choice D) is incorrect and potentially dangerous; medications should be taken as prescribed by the healthcare provider.

3. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

4. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

• A. Place a pillow under the client's knees
• B. Keep the client's legs elevated
• C. Flex the client's knee every 2 hours
• D. Apply heat to the operative knee

Correct answer: B

Rationale: Keeping the client's legs elevated is the appropriate action to prevent venous thromboembolism following a total knee arthroplasty. Elevating the legs helps promote circulation and reduce the risk of blood clots. Placing a pillow under the client's knees may provide comfort but does not address the specific postoperative complication. Flexing the client's knee every 2 hours may be contraindicated as excessive movement can disrupt the surgical site. Applying heat to the operative knee is not recommended immediately postoperatively as it can increase swelling and discomfort.

5. A client is being discharged two days after a mastectomy. Which of the following instructions should the nurse include?

• A. Wear a tight-fitting bra for support.
• B. Avoid lifting heavy objects for at least 6 weeks.
• C. Sleep on the affected side to promote healing.
• D. Begin arm exercises 24 hours after surgery.

Correct answer: B

Rationale: The correct answer is to instruct the client to avoid lifting heavy objects for at least 6 weeks after a mastectomy. This is important to prevent complications and promote proper healing. Choice A is incorrect because tight-fitting bras can increase the risk of lymphedema and discomfort. Choice C is incorrect as sleeping on the affected side can cause discomfort and interfere with healing. Choice D is incorrect as initiating arm exercises too soon after surgery can strain the surgical site and hinder recovery.

Similar Questions