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 nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. The nurse should instruct the client to monitor for and report which of the following adverse effects?

• A. Tinnitus.
• B. Photosensitivity.
• C. Urinary frequency.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin, an antibiotic commonly used to treat UTIs, can cause photosensitivity as an adverse effect. This reaction makes the skin more sensitive to sunlight, potentially leading to severe sunburns or skin damage. It is crucial for the client to be aware of this adverse effect to take precautions and report any signs of photosensitivity promptly. Choices A, C, and D are incorrect because tinnitus, urinary frequency, and insomnia are not typically associated with ciprofloxacin use. While urinary frequency might be a symptom of UTI, it is not an adverse effect of the medication itself.

3. What is the priority intervention for a patient presenting with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority intervention for a patient presenting with chest pain because it helps reduce the risk of further clot formation and improves oxygenation. Aspirin is commonly used in the initial management of suspected cardiac chest pain. Administering nitroglycerin can follow aspirin administration to help with vasodilation. Repositioning the patient or preparing for surgery are not the primary interventions for chest pain presentation.

4. While caring for a client receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?

• A. Monitor the client's urine output every 8 hours.
• B. Administer a bolus of 0.9% sodium chloride.
• C. Check the client's blood glucose level every 4 hours.
• D. Flush the TPN line with sterile water before and after administration.

Correct answer: C

Rationale: Checking the client's blood glucose level every 4 hours is essential when managing a client on TPN to monitor for hyperglycemia, a common complication. Monitoring urine output (Choice A) is important but not a priority in this scenario. Administering a bolus of 0.9% sodium chloride (Choice B) is not indicated as it is unrelated to managing TPN. Flushing the TPN line with sterile water (Choice D) is necessary, but it should be done with 0.9% sodium chloride, not water.

5. A nurse is assessing a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 minutes. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: In this scenario, the fetal heart rate (FHR) baseline of 100/min for the past 15 minutes indicates bradycardia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. This situation requires immediate intervention to address the underlying cause. Choices A, B, and D are incorrect as they are not typically associated with fetal bradycardia. Maternal fever, fetal anemia, and chorioamnionitis may have other effects on the fetus but are not primary causes of bradycardia in this context.

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