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. What is the most appropriate nursing intervention for a patient experiencing hypoglycemia?

• A. Administer IV glucose
• B. Administer oral glucose
• C. Check blood sugar in 15 minutes
• D. Provide a high-calorie snack

Correct answer: B

Rationale: The most appropriate nursing intervention for a patient experiencing hypoglycemia is to administer oral glucose. Oral glucose is usually sufficient for treating mild hypoglycemia and can be administered quickly and easily. Administering IV glucose (Choice A) is reserved for severe cases where the patient is unable to swallow or unconscious. Checking blood sugar in 15 minutes (Choice C) is important but providing glucose should come first. Providing a high-calorie snack (Choice D) may not be as rapidly effective as administering oral glucose in quickly raising blood sugar levels in a patient experiencing hypoglycemia.

3. A nurse is assessing a newborn who is 1-day old and receiving phototherapy for jaundice. Which action should the nurse take?

• A. Feed the infant glucose water every 2 hours.
• B. Ensure the newborn wears a diaper.
• C. Keep the infant's head covered with a cap.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the infant's head covered with a cap. This helps regulate the newborn's body temperature during phototherapy. Option A, feeding the infant glucose water every 2 hours, is incorrect because it is not a standard intervention for newborns receiving phototherapy. Option B, ensuring the newborn wears a diaper, may be necessary for hygiene but is not directly related to phototherapy. Option D, applying lotion to the newborn every 4 hours, is unnecessary and not indicated for managing jaundice or phototherapy.

4. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Fetal heart rate of 110/min
• B. 1+ pitting edema
• C. Blood pressure 138/80 mm Hg
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.

5. A nurse is assessing a client who is experiencing a panic attack. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Chest pain.
• D. Dilated pupils.

Correct answer: D

Rationale: During a panic attack, the sympathetic nervous system is activated, leading to physiological responses such as dilated pupils. Bradycardia (slow heart rate) and hypotension (low blood pressure) are not typically associated with panic attacks. While chest pain can occur during a panic attack due to rapid breathing and muscle tension, dilated pupils are a more specific finding related to sympathetic activation in this context.

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