Nursing Elites

1. A client is 2 days postoperative following a hip replacement surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Redness and warmth in the calf
• C. Urine output of 30 mL/hr
• D. Heart rate of 96/min

Correct answer: B

Rationale: Redness and warmth in the calf can indicate a deep vein thrombosis (DVT), which is a serious complication following hip replacement surgery. It is crucial to report this finding promptly for further evaluation and intervention. The other options, heart rates of 88/min and 96/min, are within normal limits for an adult and may not require immediate reporting. A urine output of 30 mL/hr is concerning for decreased kidney perfusion, but the priority in this case is the potential DVT due to its severe implications.

2. A client with a new diagnosis of type 2 diabetes mellitus is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will need to check my blood glucose level once a week.
• B. I will limit my carbohydrate intake to 50 grams per day.
• C. I should avoid eating foods high in protein.
• D. I should eat a snack if my blood glucose level is below 200 mg/dL.

Correct answer: D

Rationale: The correct answer is D. Clients with diabetes should eat a snack if their blood glucose level is below 70 mg/dL, not 200 mg/dL. Option A is incorrect because checking blood glucose levels once a week may not provide adequate monitoring for someone with diabetes. Option B is incorrect as a strict limit of 50 grams of carbohydrates per day may not be suitable for everyone and can vary based on individual needs. Option C is incorrect as it is important for clients with diabetes to have a balanced diet that includes protein in moderation.

3. A nurse is reviewing the medical record of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased risk of bleeding. Stool softeners help prevent straining during bowel movements, which can reduce the risk of bleeding in individuals with thrombocytopenia. Encouraging the client to floss daily (Choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is more about reducing the risk of infection rather than managing thrombocytopenia.

4. A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following client statements indicates an understanding of the teaching?

• A. I should weigh myself every morning.
• B. I should drink 2 liters of water each day.
• C. I should avoid all physical activity.
• D. I should take an extra dose of diuretic if I gain 2 pounds in a day.

Correct answer: A

Rationale: The corrected answer is A. Weighing daily is crucial for clients with heart failure to monitor fluid status since sudden weight gain can indicate fluid retention. Choice B is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice C is incorrect as some physical activity is encouraged for heart failure clients, tailored to their condition. Choice D is incorrect as adjusting medication doses should always be done under healthcare provider guidance rather than self-administration.

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

• A. Take this medication on an empty stomach.
• B. Take this medication in the evening.
• C. You should avoid taking this medication with dairy products.
• D. You should monitor for signs of infection while taking this medication.

Correct answer: D

Rationale: The correct answer is D: "You should monitor for signs of infection while taking this medication." When a client is prescribed prednisone, it is essential to monitor for signs of infection due to the immunosuppressive effects of corticosteroids. Choices A, B, and C are incorrect because prednisone does not need to be taken on an empty stomach, at a specific time of day, or avoided with dairy products.

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