Nursing Elites

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

• A. Temperature of 38°C (100.4°F).
• B. Urinary output of 40 mL/hr.
• C. Heart rate of 92/min.
• D. Capillary refill time of 2 seconds.

Correct answer: B

Rationale: The correct answer is B. A urinary output of 40 mL/hr is below the expected range and should be reported to the provider as it may indicate impaired kidney function, which is crucial to monitor in a client with septic shock. Choices A, C, and D are within acceptable ranges for a client with septic shock and do not indicate immediate concerns. A temperature of 38°C (100.4°F) is slightly elevated but can be expected in septic shock. A heart rate of 92/min is within the normal range for an adult. A capillary refill time of 2 seconds is also normal, indicating adequate peripheral perfusion.

2. A client is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

• A. A history of gastroesophageal reflux disease.
• B. Receiving a high-osmolarity formula.
• C. Sitting in a high-Fowler's position during the feeding.
• D. A residual of 65 mL 1 hr post-feeding.

Correct answer: A

Rationale: The correct answer is A. Clients with a history of gastroesophageal reflux disease are at risk for aspiration due to the potential of regurgitation, which can lead to aspiration of stomach contents into the lungs. Choice B (receiving a high-osmolarity formula) can lead to issues like diarrhea or dehydration but is not directly related to aspiration. Choice C (sitting in a high-Fowler's position during the feeding) is actually a preventive measure to reduce the risk of aspiration. Choice D (a residual of 65 mL 1 hr post-feeding) is a concern for delayed gastric emptying but not a direct risk factor for aspiration.

3. A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post maturity
• D. Head compression

Correct answer: D

Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.

4. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

5. A nurse is providing discharge teaching to a client following a cholecystectomy. Which of the following instructions should the nurse include?

• A. I should avoid lifting objects heavier than 5 pounds for 1 week.
• B. I can resume my usual activities after 2 weeks.
• C. I should expect to have pain in my right shoulder.
• D. I should follow a low-protein diet for 1 week.

Correct answer: C

Rationale: The correct answer is C. Pain in the right shoulder after a cholecystectomy is common due to residual gas from the procedure. Choices A, B, and D are incorrect. It is important to avoid heavy lifting for a longer period than just 1 week to prevent complications. Resuming usual activities after 2 weeks may not be appropriate depending on the individual's recovery. Following a low-protein diet is not a standard recommendation post-cholecystectomy.

Similar Questions