Nursing Elites

1. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?

• A. Productive cough with green sputum
• B. Temperature of 37.1°C (98.8°F)
• C. Crackles in the lung bases
• D. Oxygen saturation of 95%

Correct answer: C

Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.

2. A nurse is caring for a client who is 12 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. Respiratory rate of 16/min.
• C. Heart rate of 90/min.
• D. WBC count of 15,000/mm3.

Correct answer: D

Rationale: A WBC count of 15,000/mm3 is elevated, which may indicate infection, a common concern postoperatively. An elevated WBC count suggests the body is fighting an infection, and prompt reporting to the provider is essential for further evaluation and treatment. Serosanguineous drainage on the surgical dressing is expected in the immediate postoperative period, respiratory rate of 16/min is within the normal range, and a heart rate of 90/min is also within an acceptable range postoperatively. Therefore, these findings do not raise immediate concerns that necessitate reporting to the provider.

3. A nurse is teaching a newly licensed nurse about the stages of wound healing. The nurse should include in the teaching that collagen is added to the wound during which of the following stages?

• A. Hemostasis phase.
• B. Inflammatory phase.
• C. Proliferative phase.
• D. Maturation phase.

Correct answer: C

Rationale: The correct answer is C: Proliferative phase. During the proliferative phase of wound healing, collagen is added to the wound to promote tissue regeneration. In the hemostasis phase (choice A), the primary goal is to stop bleeding by forming a blood clot. The inflammatory phase (choice B) involves cleaning the wound and preparing it for healing. The maturation phase (choice D) is when the wound undergoes remodeling and gains strength, but collagen addition primarily occurs during the proliferative phase.

4. A nurse is providing discharge teaching to a client who has had a stroke. Which of the following instructions should the nurse include?

• A. Avoid taking anticoagulant medication.
• B. Limit fluid intake to 1,000 mL per day.
• C. Avoid isometric exercises during recovery.
• D. Perform range-of-motion exercises daily.

Correct answer: D

Rationale: The correct answer is D: Perform range-of-motion exercises daily. After a stroke, performing range-of-motion exercises can help prevent complications such as joint stiffness and contractures. Options A, B, and C are incorrect. Anticoagulant medications are often prescribed to prevent blood clots after a stroke, fluid intake should be adequate unless indicated otherwise, and isometric exercises can be beneficial during recovery.

5. A client with iron deficiency anemia has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take with a glass of milk to prevent stomach upset.
• B. Take with orange juice to enhance absorption.
• C. Take on an empty stomach to increase absorption.
• D. Take with food to reduce gastrointestinal upset.

Correct answer: C

Rationale: The correct instruction is to take ferrous sulfate on an empty stomach to increase absorption. This is because taking it with food or dairy products like milk can reduce its absorption. Orange juice is not recommended as it may interfere with the absorption of iron. Taking ferrous sulfate on an empty stomach may cause gastrointestinal upset, but this can be minimized by gradually increasing the dose.

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