Nursing Elites

1. A nurse is caring for a client who is 36 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 92/min
• B. Serosanguineous wound drainage
• C. Yellow wound drainage
• D. Blood pressure of 118/76 mm Hg

Correct answer: C

Rationale: Yellow wound drainage can indicate infection, especially 36 hours postoperative, and should be reported to the provider promptly. Serosanguineous drainage is a normal finding in the early stages of wound healing, and a heart rate of 92/min and a blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client. Therefore, the nurse should prioritize reporting the yellow wound drainage as it may require immediate intervention.

2. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?

• A. Massage the affected extremity every 4 hours.
• B. Encourage the client to remain on bed rest.
• C. Apply cold packs to the affected extremity.
• D. Encourage the client to ambulate frequently.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.

3. A nurse is preparing to administer a dose of vancomycin IV to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse take?

• A. Administer the medication over 15 minutes.
• B. Monitor the client's urine output every 8 hours.
• C. Check the client's creatinine level before administering the medication.
• D. Assess the client for a history of allergies to antibiotics.

Correct answer: C

Rationale: The correct action for the nurse to take is to check the client's creatinine level before administering vancomycin. Vancomycin is known to be nephrotoxic, so assessing the client's renal function before administering the medication is crucial to prevent further kidney damage. Administering the medication over 15 minutes (Choice A) is not the priority in this scenario as renal function assessment takes precedence. Monitoring urine output (Choice B) is important for assessing renal function but checking creatinine level directly provides more accurate information. Assessing for allergies to antibiotics (Choice D) is also important but not as essential as checking the creatinine level due to the nephrotoxic nature of vancomycin.

4. A healthcare professional is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?

• A. PaO2 level of 89 mm Hg
• B. PaCO2 level of 55 mm Hg
• C. HCO3 level of 25 mEq/L
• D. pH level of 7.37

Correct answer: B

Rationale: The correct answer is B. A high PaCO2 level (55 mm Hg) in a client with chronic emphysema suggests respiratory acidosis, which requires further treatment. In chronic emphysema, impaired gas exchange leads to elevated carbon dioxide levels in the blood. Option A (PaO2 level of 89 mm Hg) is near the normal range and does not indicate immediate treatment. Option C (HCO3 level of 25 mEq/L) and option D (pH level of 7.37) are within normal limits and do not suggest the need for further treatment in this context.

5. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following interventions should the nurse implement?

• A. Provide a low-sodium diet.
• B. Administer lorazepam as prescribed.
• C. Keep the client in a supine position.
• D. Place the client in restraints as prescribed.

Correct answer: B

Rationale: Administering lorazepam is the appropriate intervention for a client experiencing acute alcohol withdrawal. Lorazepam helps reduce agitation and prevent complications during this withdrawal phase. Choice A, providing a low-sodium diet, is not directly related to managing alcohol withdrawal symptoms. Choice C, keeping the client in a supine position, is not necessary and may not address the client's withdrawal symptoms. Choice D, placing the client in restraints, should only be considered if the client is at risk of harming themselves or others, but it is not the primary intervention for managing alcohol withdrawal.

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