Nursing Elites

1. 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.

2. A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I should avoid using salt substitutes while taking this medication.
• B. I should take this medication with food to prevent nausea.
• C. I should increase my intake of potassium-rich foods while taking this medication.
• D. I should limit my fluid intake while taking this medication.

Correct answer: A

Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.

3. A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following findings indicates the medication is effective?

• A. The client's urine output decreases.
• B. The client's blood pressure increases.
• C. The client's heart rate increases.
• D. The client's urine specific gravity decreases.

Correct answer: A

Rationale: The correct answer is A: 'The client's urine output decreases.' Desmopressin is used to treat diabetes insipidus by reducing excessive urine output. Therefore, a decrease in urine output indicates that the medication is effectively controlling the symptoms. Choices B, C, and D are incorrect because desmopressin primarily affects urine output, not blood pressure, heart rate, or urine specific gravity.

4. A nurse is caring for a client who has a prescription for spironolactone. Which of the following laboratory values should the nurse monitor?

• A. Sodium 140 mEq/L
• B. Calcium 9.5 mg/dL
• C. Potassium 5.2 mEq/L
• D. Magnesium 2.0 mEq/L

Correct answer: C

Rationale: The correct answer is C: Potassium 5.2 mEq/L. A potassium level of 5.2 mEq/L is elevated and should be monitored in clients taking spironolactone, which is a potassium-sparing medication. Monitoring potassium levels is crucial as spironolactone can cause hyperkalemia. Choices A, B, and D are incorrect because sodium, calcium, and magnesium levels are not typically affected by spironolactone. Therefore, the nurse should primarily focus on monitoring the potassium levels in this scenario.

5. A client is experiencing a seizure. Which of the following interventions should the nurse implement?

• A. Place a tongue depressor in the client's mouth
• B. Loosen tight clothing around the client
• C. Restrain the client's arms and legs
• D. Administer 100% oxygen via non-rebreather mask

Correct answer: B

Rationale: During a seizure, it is essential to loosen tight clothing around the client to prevent injury and promote adequate ventilation. Placing any objects, like a tongue depressor, in the client's mouth can lead to airway obstruction or injury. Restraining the client's arms and legs can exacerbate the situation by increasing muscle rigidity and potentially causing injury. Administering oxygen via a non-rebreather mask is not typically indicated during a seizure unless respiratory distress is present.

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