Nursing Elites

1. A nurse is caring for a client who is 2 hours postoperative following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Chest tube drainage of 60 mL/hr
• B. Oxygen saturation of 95%
• C. Chest tube drainage of 120 mL/hr
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

2. What is the most important assessment for a patient post-op to monitor for complications?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood glucose levels
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.

3. A client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the hip?

• A. Position the client's legs in adduction
• B. Place a pillow between the client's legs when turning
• C. Keep the client in a low Fowler's position
• D. Turn the client onto the affected side

Correct answer: B

Rationale: Placing a pillow between the client's legs when turning is essential to prevent hip dislocation post hip replacement surgery. This action helps maintain proper alignment of the hip joint and prevents adduction, which can lead to dislocation. Positioning the client's legs in adduction (choice A) can increase the risk of hip dislocation. Keeping the client in a low Fowler's position (choice C) or turning the client onto the affected side (choice D) does not directly address hip dislocation prevention.

4. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?

• A. Increased appetite
• B. Pallor
• C. Tachycardia
• D. Hypertension

Correct answer: B

Rationale: The correct answer is B: Pallor. Pallor, which is paleness of the skin, is a common sign of anemia due to a decreased number of red blood cells or hemoglobin levels. This results in reduced oxygen-carrying capacity, leading to the paleness of the skin. Choice A, increased appetite, is not typically associated with anemia. Choice C, tachycardia (increased heart rate), can be present in anemia as the body compensates for decreased oxygenation. Choice D, hypertension (high blood pressure), is not a common finding in anemia; instead, low blood pressure may be observed due to decreased blood volume.

5. A client with a history of depression and experiencing a situational crisis is being assessed by a nurse. What action should the nurse take first?

• A. Notify the client's support system.
• B. Help the client identify personal strengths.
• C. Confirm the client's perception of the event.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: When a client with a history of depression is experiencing a situational crisis, the first action the nurse should take is to notify the client's support system. This is crucial as the client may require immediate assistance and support. While helping the client identify personal strengths and confirming the client's perception of the event are important aspects of the assessment and intervention process, notifying the support system takes priority in ensuring the client's safety and well-being. Teaching relaxation techniques may be beneficial but addressing the client's immediate crisis through support system notification is the most appropriate initial action.

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