Nursing Elites

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

• A. Bowel sounds present in all four quadrants
• B. Temperature of 37.5°C (99.5°F)
• C. Scant urine output
• D. Serosanguineous wound drainage

Correct answer: D

Rationale: The correct answer is D: 'Serosanguineous wound drainage.' Serosanguineous drainage should be reported in postoperative clients as it may indicate complications such as infection or impaired wound healing. Options A, B, and C are expected findings in a postoperative client. Bowel sounds present in all four quadrants indicate normal gastrointestinal function, a temperature of 37.5°C (99.5°F) is within the normal range, and scant urine output may be expected initially due to factors like anesthesia and fluid shifts postoperatively.

2. A client with iron-deficiency anemia is being taught about dietary management by a nurse. Which of the following foods should the nurse recommend?

• A. Oatmeal
• B. Red meat
• C. Bananas
• D. Whole grains

Correct answer: B

Rationale: The correct answer is B: Red meat. Red meat is a good dietary source of heme iron, which is easily absorbed by the body and beneficial for individuals with iron-deficiency anemia. Oatmeal, bananas, and whole grains are not as rich in iron compared to red meat and may not provide sufficient amounts to help manage iron-deficiency anemia effectively.

3. A nurse is assessing a client who has a new diagnosis of heart failure. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Serum potassium level of 4.0 mEq/L
• C. Weight gain of 2 kg (4.4 lb) in 2 days
• D. Heart rate of 76/min

Correct answer: C

Rationale: A weight gain of 2 kg (4.4 lb) in 2 days can indicate fluid retention, which is a sign of worsening heart failure and should be reported. This rapid weight gain suggests a fluid overload, putting the client at risk for complications. A heart rate of 90/min is slightly elevated but not as concerning as a sudden significant weight gain. The serum potassium level of 4.0 mEq/L is within the normal range and does not directly indicate worsening heart failure. A heart rate of 76/min is within the normal range and does not raise immediate concerns related to heart failure.

4. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine-second duration, and the fetal heart rate is 170 to 180 beats per minute. Which of the following actions should the nurse take?

• A. Discontinue oxytocin infusion
• B. Increase oxytocin infusion
• C. Decrease oxytocin infusion
• D. Maintain oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing frequent contractions with a short duration and an elevated fetal heart rate, indicating potential fetal distress. Discontinuing the oxytocin infusion is crucial to prevent further complications and restore normal fetal parameters. Increasing or maintaining the oxytocin infusion could exacerbate the situation, leading to more distress for the fetus. Decreasing the oxytocin infusion may not be sufficient to address the current issue and could delay the improvement of fetal well-being.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values indicates the TPN is effective?

• A. Albumin 3.5 g/dL
• B. Hemoglobin 8 g/dL
• C. WBC count 15,000/mm3
• D. Blood glucose 110 mg/dL

Correct answer: D

Rationale: The correct answer is D. A blood glucose level of 110 mg/dL indicates that the TPN is effective in maintaining normal glucose levels. Hemoglobin level (choice B) is related to anemia and not directly indicative of TPN effectiveness. Albumin level (choice A) is a marker of nutritional status over a longer term and may not reflect immediate TPN effectiveness. White blood cell count (choice C) is related to infection or inflammation and is not a direct indicator of TPN effectiveness.

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