Nursing Elites

1. A client who is 48 hours postoperative following abdominal surgery is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min
• B. Sanguineous drainage on the surgical dressing
• C. Temperature of 37.5°C (99.5°F)
• D. Serous drainage on the surgical dressing

Correct answer: B

Rationale: Sanguineous drainage from the surgical site 48 hours after surgery could indicate a complication such as hemorrhage or infection and should be reported. Sanguineous drainage is typically seen in the early postoperative period due to the presence of blood. Serous drainage, on the other hand, is normal in the later stages of wound healing. A heart rate of 80/min is within the normal range for an adult. A temperature of 37.5°C (99.5°F) is slightly elevated but not a concerning finding in the absence of other symptoms.

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

• A. Heart rate of 90/min
• B. Capillary refill of 2 seconds
• C. Wound drainage of 30 mL in 8 hours
• D. Warmth and redness in the calf

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

3. A nurse is providing discharge instructions to a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should have my vision checked regularly while taking this medication.
• B. This medication can cause my urine to turn reddish-orange.
• C. I need to wear sunscreen and protective clothing while taking this medication.
• D. I will discontinue this medication if I experience nausea.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause a harmless reddish-orange discoloration of body fluids, including urine. Choice A is not related to rifampin; vision changes are not a common side effect of the medication. Choice C is more relevant to medications that cause photosensitivity reactions, not specifically rifampin. Choice D is incorrect because nausea is a common side effect of rifampin, but it does not warrant immediate discontinuation of the medication.

4. A client with Raynaud's disease is being cared for by a nurse. What intervention should the nurse implement?

• A. Maintain a warm temperature in the client's room.
• B. Administer epinephrine for acute episodes.
• C. Provide information about stress management.
• D. Give glucocorticoid steroid twice a day.

Correct answer: C

Rationale: The correct intervention for a client with Raynaud's disease is to provide information about stress management. Stress can trigger Raynaud's episodes, so managing stress can help reduce the frequency and severity of the condition. Maintaining a warm temperature in the client's room (Choice A) is important to prevent vasoconstriction and worsening of symptoms. Administering epinephrine (Choice B) is not a standard treatment for Raynaud's disease. Giving glucocorticoid steroids (Choice D) is not the primary treatment for Raynaud's disease and is not typically prescribed for this condition.

5. A nurse is caring for a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min, and the PR interval is 0.24 seconds. What cardiac rhythm should the nurse interpret this finding as?

• A. First-degree AV block.
• B. Premature ventricular contraction.
• C. Sinus bradycardia.
• D. Atrial fibrillation.

Correct answer: A

Rationale: The correct answer is A: First-degree AV block. A PR interval of 0.24 seconds indicates a prolonged PR interval, which is characteristic of first-degree AV block. This rhythm is considered benign and often does not require treatment. Choice B, premature ventricular contraction, is characterized by early, abnormal ventricular contractions and would not be indicated by the findings provided. Choice C, sinus bradycardia, would present with a normal PR interval but a heart rate less than 60 beats per minute. Choice D, atrial fibrillation, is characterized by an irregularly irregular rhythm with no identifiable P waves, which does not align with the findings of a prolonged PR interval in this scenario.

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