Nursing Elites

1. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Serous drainage on the dressing
• C. Temperature 37.3°C (99.1°F)
• D. Calf pain on dorsiflexion

Correct answer: D

Rationale: The correct answer is D. Calf pain on dorsiflexion following knee surgery may indicate a complication such as deep vein thrombosis, which is a serious condition requiring medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal range for a client post knee surgery and do not typically indicate immediate complications that require urgent reporting.

2. A nurse is caring for a child who has cystic fibrosis and is receiving postural drainage. Which of the following actions should the nurse take?

• A. Perform the procedure after meals.
• B. Administer bronchodilators before the procedure.
• C. Hold hand flat to perform percussion.
• D. Perform the procedure twice a day.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a child with cystic fibrosis receiving postural drainage is to hold the hand flat to perform percussion. This technique allows for effective chest physiotherapy. Choice A is incorrect because postural drainage should be performed before meals to prevent vomiting during the procedure. Choice B is incorrect because bronchodilators are typically administered before postural drainage to help open up the airways. Choice D is incorrect as the frequency of postural drainage may vary depending on the individual's condition, so performing it twice a day may not be appropriate for all patients.

3. A client with a new diagnosis of heart failure is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Limit sodium intake to 4 grams per day.
• B. Weigh yourself daily to monitor for fluid retention.
• C. Drink 2 liters of water each day.
• D. Increase physical activity gradually.

Correct answer: B

Rationale: The correct answer is B. Weighing oneself daily is crucial in monitoring fluid retention, a key aspect in managing heart failure. This helps in detecting early signs of fluid buildup, prompting timely interventions. Choice A is incorrect as the recommended sodium intake for heart failure clients is usually lower, around 2-3 grams daily. Choice C is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice D is incorrect as clients with heart failure should consult healthcare providers before significantly altering their physical activity levels.

4. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: Obtaining a prescription for restraint within 4 hours is the correct action when managing restraints in a client with acute mania. This timeframe ensures that the use of restraints is promptly evaluated and authorized by a healthcare provider. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary and may delay appropriate care. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is important but not the immediate priority when dealing with obtaining a prescription for restraints. Documenting the client's condition every 15 minutes (Choice D) is essential for monitoring, but the priority is to secure a prescription for restraints promptly.

5. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse should identify that which of the following findings is a manifestation of opioid toxicity?

• A. Bradypnea.
• B. Tachycardia.
• C. Hypertension.
• D. Diaphoresis.

Correct answer: A

Rationale: Corrected Rationale: Bradypnea, or slow breathing, is a common sign of opioid toxicity. When a client is experiencing opioid toxicity, the respiratory system is usually the most affected, leading to a decrease in the respiratory rate (bradypnea). Tachycardia (increased heart rate), hypertension (high blood pressure), and diaphoresis (excessive sweating) are not typical manifestations of opioid toxicity. Therefore, the correct answer is bradypnea.

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