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 nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

• A. Monitor the client's urinary output.
• B. Assist the client to splint the incision with a pillow when coughing.
• C. Provide the client with a clear liquid diet.
• D. Encourage the client to ambulate in the hallway.

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

3. A nurse is assessing a client who is receiving opioid analgesics for pain management. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 20/min
• B. Blood pressure of 118/76 mm Hg
• C. Heart rate of 88/min
• D. Oxygen saturation of 94%

Correct answer: C

Rationale: The correct answer is C. A heart rate of 88/min is a normal finding; therefore, it does not require immediate reporting to the provider. The respiratory rate of 20/min, blood pressure of 118/76 mm Hg, and oxygen saturation of 94% are also within normal ranges and do not indicate any immediate concerns. However, a serum potassium level of 3.0 mEq/L indicates hypokalemia, which can be a serious issue and should be reported to the provider for further evaluation and management.

4. A client with acute diverticulitis should have which intervention included in the care plan?

• A. Administer a cleansing enema.
• B. Initiate a low-fiber diet.
• C. Apply moist heat to the abdomen.
• D. Provide a clear liquid diet.

Correct answer: B

Rationale: The correct intervention for a client with acute diverticulitis is to initiate a low-fiber diet. A low-fiber diet helps manage acute diverticulitis by reducing irritation to the colon, allowing it to heal. Administering a cleansing enema (Choice A) can worsen diverticulitis by increasing pressure within the colon. Applying moist heat to the abdomen (Choice C) may provide comfort but does not address the underlying cause. Providing a clear liquid diet (Choice D) is not ideal for diverticulitis management as it lacks the necessary nutrients for healing and may not provide enough bulk to prevent further irritation.

5. A nurse is teaching a client about home care following cataract surgery. Which of the following statements should the nurse include?

• A. You should wear a protective eye shield while sleeping.
• B. You should avoid bending over to pick things up.
• C. You should apply pressure to your eye if you feel pain.
• D. You should resume wearing your regular glasses immediately.

Correct answer: A

Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.

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