Nursing Elites

1. A patient is 1 day postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

• A. Administer aspirin for pain management.
• B. Keep the affected leg in a dependent position.
• C. Flex the affected knee for 2 to 3 minutes every hour.
• D. Apply ice packs to the affected knee.

Correct answer: D

Rationale: The correct action for a client 1 day postoperative following a total knee arthroplasty is to apply ice packs to the affected knee. Ice packs help reduce swelling and pain in such clients. Administering aspirin is contraindicated due to the risk of bleeding postoperatively. Keeping the affected leg in a dependent position can impair circulation and increase the risk of complications. Flexing the affected knee for extended periods can strain the surgical site and hinder the healing process.

2. A nurse in a pediatric clinic is reviewing the laboratory test results of a school-age child. Which of the following findings should the nurse report to the provider?

• A. Hgb 12.5 g/dL.
• B. Platelets 250,000/mm³.
• C. Hct 40%.
• D. WBC 14,000/mm³.

Correct answer: D

Rationale: The correct answer is D. A WBC count of 14,000/mm³ is elevated, indicating a potential infection or inflammation, and should be reported to the provider for further evaluation and management. Choices A, B, and C are within normal ranges and do not require immediate reporting as they indicate normal hemoglobin, platelet count, and hematocrit levels for a school-age child.

3. A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?

• A. Platelets 250,000/mm³
• B. aPTT 60 seconds
• C. Hemoglobin 15 g/dL
• D. INR 1.5

Correct answer: B

Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.

4. What is the best intervention for a patient experiencing severe hypoglycemia?

• A. Administer IV dextrose
• B. Administer oral glucose
• C. Monitor blood sugar levels
• D. Recheck blood sugar in 15 minutes

Correct answer: A

Rationale: The best intervention for a patient experiencing severe hypoglycemia is to administer IV dextrose. This intervention is necessary to rapidly raise blood sugar levels in critical situations. Administering oral glucose may not be effective in severe cases as the patient may be unable to consume it. Monitoring blood sugar levels and rechecking blood sugar in 15 minutes are important steps but not the initial best intervention for severe hypoglycemia.

5. A client is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Temperature of 37.1°C (98.8°F)
• C. Serosanguineous wound drainage
• D. Urine output of 25 mL/hr

Correct answer: D

Rationale: A urine output of 25 mL/hr is a sign of oliguria, which may indicate dehydration or kidney impairment and should be reported. A heart rate of 90/min is within the normal range (60-100/min) for adults at rest and may be expected postoperatively. A temperature of 37.1°C (98.8°F) is within the normal range (36.1-37.2°C or 97-99°F) and does not indicate an immediate concern. Serosanguineous wound drainage is a common finding postoperatively and indicates a normal healing process.

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