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 nurse is providing dietary teaching to a client who is at 8 weeks of gestation and has a body mass index (BMI) of 24. Which of the following instructions should the nurse include?

• A. You should increase your caloric intake by 600 calories per day.
• B. You should increase your caloric intake by 300 calories per day.
• C. You should maintain your prepregnancy caloric intake during the first trimester.
• D. You should increase your caloric intake by 150 calories per day.

Correct answer: B

Rationale: During the first trimester, it is recommended to increase caloric intake by 300 calories per day to support fetal growth and development. Choice A suggesting an increase of 600 calories is excessive and unnecessary. Choice C advising to maintain prepregnancy caloric intake could lead to inadequate nutrition for the developing fetus. Choice D recommending an increase of 150 calories is insufficient to meet the increased energy demands of pregnancy.

3. A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Use a 21-gauge needle for injection.
• B. Inject the medication into the client's deltoid muscle.
• C. Administer the medication within 5 cm (2 in) of the umbilicus.
• D. Massage the injection site after administration.

Correct answer: C

Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.

4. A nurse is caring for a client who has acute pancreatitis. Which of the following laboratory results should the nurse expect to be elevated?

• A. Serum creatinine.
• B. Amylase.
• C. Hemoglobin.
• D. Blood glucose.

Correct answer: B

Rationale: The correct answer is B: Amylase. Amylase is typically elevated in clients with acute pancreatitis due to inflammation of the pancreas. Elevated serum creatinine levels are more indicative of kidney dysfunction rather than pancreatitis. Hemoglobin levels are not directly related to pancreatitis. While blood glucose levels can be affected by pancreatitis, they are not typically the primary laboratory result expected to be elevated in this condition.

5. A nurse is caring for a client who is receiving chemotherapy. Which of the following findings should the nurse report to the provider?

• A. Alopecia
• B. Weight gain of 1 kg (2.2 lb) in 24 hours
• C. White blood cell count of 6,000/mm³
• D. Temperature of 37.2°C (99°F)

Correct answer: B

Rationale: The correct answer is B. A weight gain of 1 kg (2.2 lb) in 24 hours is concerning as it indicates fluid retention, which can be a sign of complications in clients receiving chemotherapy. Rapid weight gain can be associated with conditions like fluid overload or electrolyte imbalances, which need prompt medical attention. Choices A, C, and D are not typically immediate concerns related to chemotherapy. Alopecia (choice A) is a common side effect of chemotherapy, a white blood cell count of 6,000/mm³ (choice C) falls within the normal range, and a temperature of 37.2°C (99°F) (choice D) is slightly elevated but not a critical finding in this context.

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