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 vision loss is being cared for by a nurse. Which of the following actions should the nurse take?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Touch the client gently to announce presence

Correct answer: A

Rationale: The correct action for the nurse to take is to keep objects in the client's room in the same place. This helps individuals with vision loss navigate their environment more easily by creating a familiar and consistent layout. Choice B, ensuring high-wattage lighting, may not be suitable for all clients with vision loss and can cause discomfort or glare. Approaching the client from the side (Choice C) can startle them and is not recommended. Touching the client (Choice D) without warning may cause anxiety or distress, so it's important to announce presence verbally.

3. A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings is a priority for the nurse to report?

• A. Low back pain
• B. Tachycardia
• C. Flushed skin
• D. Headache

Correct answer: B

Rationale: The correct answer is B: Tachycardia. Tachycardia can indicate a hemolytic transfusion reaction, a severe and life-threatening complication of blood transfusion. The nurse should report tachycardia immediately to prevent further complications. Low back pain, flushed skin, and headache are also important to monitor during a blood transfusion, but they are not as indicative of a severe transfusion reaction as tachycardia.

4. What is the best intervention for a patient experiencing severe hypoglycemia?

• A. Administer IV dextrose
• B. Administer oral glucose
• C. Monitor blood sugar levels
• D. Recheck blood sugar in 15 minutes

Correct answer: A

Rationale: The best intervention for a patient experiencing severe hypoglycemia is to administer IV dextrose. This intervention is necessary to rapidly raise blood sugar levels in critical situations. Administering oral glucose may not be effective in severe cases as the patient may be unable to consume it. Monitoring blood sugar levels and rechecking blood sugar in 15 minutes are important steps but not the initial best intervention for severe hypoglycemia.

5. 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.

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