Nursing Elites

1. A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?

• A. Urine output of 30 mL/hr
• B. Pink-tinged urine
• C. Small blood clots in the urine
• D. Blood pressure of 114/78 mm Hg

Correct answer: C

Rationale: The presence of small blood clots in the urine is an expected finding after a TURP due to the surgical manipulation of the prostate bed and the bladder. However, larger clots can indicate excessive bleeding and should be reported promptly. Urine output of 30 mL/hr is within the expected range for post-TURP clients, indicating adequate kidney perfusion. Pink-tinged urine is also normal after a TURP due to minor bleeding from the surgical site. A blood pressure of 114/78 mm Hg is within normal limits and does not require immediate reporting.

2. A nurse is providing teaching to a client who has osteoporosis. Which of the following instructions should the nurse include?

• A. Take a calcium supplement once daily.
• B. Walk for 30 minutes three times per week.
• C. Avoid weight-bearing exercises.
• D. Increase intake of vitamin D.

Correct answer: B

Rationale: The correct answer is B. Walking regularly is beneficial for clients with osteoporosis as it helps maintain bone density and prevent fractures. Choice A is not the most appropriate because clients with osteoporosis often require more than just calcium supplements. Choice C is incorrect as weight-bearing exercises actually help strengthen bones. Choice D is important, but walking regularly has a more direct impact on bone health in clients with osteoporosis.

3. A nurse is caring for a client who is 1 day postoperative following an open reduction and internal fixation of the right tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 88/min
• D. Pallor of the affected extremity

Correct answer: D

Rationale: Pallor of the affected extremity could indicate impaired circulation, such as compromised blood flow to the area, which is crucial to monitor postoperatively. This finding suggests potential vascular compromise or decreased blood supply to the extremity, which is a serious concern and should be reported promptly to the provider for further evaluation and intervention. Serous drainage on the dressing is a normal finding in the immediate postoperative period and does not necessarily indicate a complication requiring immediate provider notification. Capillary refill of 2 seconds is within the normal range (less than 3 seconds) and indicates adequate peripheral perfusion. A heart rate of 88/min is also within the normal range for an adult and is not typically a cause for immediate concern postoperatively.

4. A client with diabetes mellitus is being taught by a nurse about managing blood glucose levels. Which of the following client statements indicates an understanding of the teaching?

• A. I will eat a snack if my blood glucose level is below 70 mg/dL.
• B. I will take my insulin if my blood glucose level is above 200 mg/dL.
• C. I will check my blood glucose level once a week.
• D. I will take my insulin only when I feel symptoms of hyperglycemia.

Correct answer: A

Rationale: Choice A is the correct answer because consuming a snack when the blood glucose level is below 70 mg/dL helps prevent hypoglycemia in clients with diabetes mellitus. Choice B is incorrect because taking insulin when blood glucose is high (above 200 mg/dL) helps manage hyperglycemia, not hypoglycemia. Choice C is incorrect as checking blood glucose levels once a week is insufficient for proper diabetes management, which typically requires more frequent monitoring. Choice D is incorrect because waiting for symptoms of hyperglycemia to take insulin can lead to uncontrolled blood glucose levels.

5. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

• A. Contractions lasting 80 seconds.
• B. FHR baseline 170/min.
• C. Early decelerations in the FHR.
• D. Temperature 37.4°C (99.3°F).

Correct answer: B

Rationale: The correct answer is B. An FHR baseline of 170/min is considered tachycardia, which is above the normal range during labor and requires immediate attention. High FHR can indicate fetal distress or maternal fever. Choice A, contractions lasting 80 seconds, are within normal range for active labor. Choice C, early decelerations in the FHR, are usually benign and do not typically require immediate intervention. Choice D, a temperature of 37.4°C (99.3°F), is within normal limits.

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