Nursing Elites

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

• A. Serosanguineous drainage on the surgical dressing.
• B. Heart rate of 88/min.
• C. Blood pressure of 118/76 mm Hg.
• D. Temperature of 38.8°C (101.8°F).

Correct answer: D

Rationale: A temperature of 38.8°C (101.8°F) is above the normal range and may indicate infection, which should be reported. Elevated temperature postoperatively can be a sign of infection, especially in the early postoperative period. Serosanguineous drainage on the surgical dressing is expected in the early postoperative period. A heart rate of 88/min and a blood pressure of 118/76 mm Hg are within normal ranges and do not necessarily indicate a complication postoperatively.

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

• A. Take this medication on an empty stomach.
• B. Take this medication at bedtime.
• C. Take this medication with food.
• D. Take this medication with a calcium supplement.

Correct answer: A

Rationale: The correct answer is A: 'Take this medication on an empty stomach.' Levothyroxine should be taken on an empty stomach to enhance absorption. Taking it with food or at bedtime can interfere with its absorption. Calcium supplements should also be avoided when taking levothyroxine as they can reduce its absorption.

3. A client reports intimate partner violence to a nurse. What is the nurse's priority action?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Ensure the client has access to legal services.

Correct answer: A

Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.

4. What is the appropriate nursing response when a patient refuses blood transfusion due to religious beliefs?

• A. Respect the patient's decision and notify the provider
• B. Attempt to persuade the patient to accept the transfusion
• C. Document the refusal and notify the healthcare provider
• D. Provide education on the benefits of blood transfusion

Correct answer: A

Rationale: The correct answer is A: "Respect the patient's decision and notify the provider." When a patient refuses a blood transfusion due to religious beliefs, it is essential to respect their autonomy and religious beliefs. Attempting to persuade the patient (Choice B) goes against the principle of respect for autonomy and can lead to ethical dilemmas. Documenting the refusal and notifying the healthcare provider (Choice C) is important for legal and ethical purposes but should be preceded by respecting the patient's decision. Providing education on the benefits of blood transfusion (Choice D) may be appropriate in other situations but is not indicated when a patient refuses based on religious beliefs.

5. A nurse is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Client reports taking warfarin
• B. Client has a history of hypertension
• C. Client ate a light breakfast 2 hours prior
• D. Client reports a history of smoking 10 cigarettes a day

Correct answer: A

Rationale: The correct answer is A. Warfarin is an anticoagulant that increases the risk of bleeding during surgery. It is crucial for the provider to be informed about the client taking warfarin to adjust the treatment plan accordingly. Choices B, C, and D are not as critical to report for surgical planning. A history of hypertension (B) is important but may not require immediate intervention for surgery. Eating a light breakfast 2 hours prior (C) is a normal preoperative instruction. Smoking history (D) is relevant for overall health assessment but is not as urgent as the use of warfarin before surgery.

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