Nursing Elites

1. A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?

• A. Abdominal pain radiating to the right shoulder.
• B. Absent bowel sounds.
• C. Brown drainage on the surgical dressing.
• D. Urine output of 25 mL/hr.

Correct answer: D

Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.

2. When caring for a client with a wound infection, what is the most important nursing action?

• A. Change the dressing every 4 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial in identifying the specific infecting organism and choosing the most effective antibiotic treatment. Changing the dressing every 4 hours (choice A) may be too frequent and can disrupt the wound healing process. Cleansing the wound with alcohol-based solutions (choice C) can be too harsh and may delay healing. Applying a wet-to-dry dressing (choice D) can cause trauma to the wound bed and is not recommended for infected wounds.

3. What are the signs of an acute myocardial infarction?

• A. Chest pain radiating to the arm and shortness of breath
• B. Nausea, vomiting, and high fever
• C. Headache, confusion, and low blood pressure
• D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

4. A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?

• A. I will avoid feeding my baby for 12 hours
• B. I will apply diaper cream during each diaper change
• C. I will give my baby water between feedings
• D. I will apply warm compresses for my baby's comfort

Correct answer: B

Rationale: The correct answer is B. Applying diaper cream during each diaper change is important to prevent skin breakdown in infants with rotavirus. Rotavirus can cause diarrhea, which can lead to skin irritation. Avoiding feeding the baby for 12 hours (choice A) can lead to dehydration and is not appropriate. Giving water between feedings (choice C) can further contribute to dehydration. Applying warm compresses (choice D) may provide comfort but does not address the specific issue of preventing skin breakdown associated with rotavirus.

5. A nurse is reviewing the medical record of a client who is receiving warfarin for atrial fibrillation. Which of the following findings should the nurse report to the provider?

• A. International normalized ratio (INR) of 2.5
• B. Platelet count of 180,000/mm³
• C. Prothrombin time (PT) of 12 seconds
• D. Partial thromboplastin time (PTT) of 30 seconds

Correct answer: C

Rationale: A prothrombin time (PT) of 12 seconds is below the therapeutic range for warfarin and indicates a need for dosage adjustment. The correct answer is C. A normal International normalized ratio (INR) for a client on warfarin therapy is usually between 2.0 to 3.0; therefore, an INR of 2.5 is within the expected range. A platelet count of 180,000/mm³ is within the normal range (150,000 to 450,000/mm³) and does not require immediate reporting. A partial thromboplastin time (PTT) of 30 seconds is also within the normal range (25-35 seconds) and does not indicate a need for urgent action.

Similar Questions