Nursing Elites

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

• A. Blood pressure of 110/70 mm Hg
• B. Temperature of 37.2°C (99°F)
• C. Serosanguineous wound drainage
• D. Bile-colored drainage from the surgical site

Correct answer: D

Rationale: Bile-colored drainage from the surgical site can indicate a bile leak, which is an abnormal finding and should be reported. A blood pressure of 110/70 mm Hg and a temperature of 37.2°C (99°F) are within normal ranges for a postoperative client. Serosanguineous wound drainage, which is a mix of blood and serum, is expected following a surgery like cholecystectomy. Therefore, choices A, B, and C are not findings that require immediate reporting.

2. A nurse is caring for a client who has a wound infection and is receiving gentamicin. Which of the following laboratory values should the nurse monitor to detect an adverse effect of this medication?

• A. Creatinine.
• B. Aspartate aminotransferase (AST).
• C. White blood cell count.
• D. Serum glucose.

Correct answer: A

Rationale: The correct answer is A: Creatinine. Gentamicin can cause nephrotoxicity, leading to impaired kidney function. Monitoring creatinine levels helps the nurse detect any potential kidney damage. Choice B, Aspartate aminotransferase (AST), is not typically affected by gentamicin. Choice C, White blood cell count, is not directly related to gentamicin adverse effects. Choice D, Serum glucose, is not specifically monitored for gentamicin adverse effects.

3. Which electrolyte imbalance is most concerning for a patient on furosemide?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss through increased urinary excretion, making hypokalemia the most concerning electrolyte imbalance. Hyponatremia (Choice B) is not typically associated with furosemide use. Hyperkalemia (Choice C) is less likely due to furosemide's potassium-wasting effect. Hypercalcemia (Choice D) is not a common electrolyte imbalance seen with furosemide.

4. A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the provider?

• A. Constant bubbling in the water seal chamber.
• B. Intermittent bubbling in the suction control chamber.
• C. Tidaling in the water seal chamber.
• D. Drainage of 75 mL in the first 24 hours.

Correct answer: A

Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.

5. A nurse is reviewing the laboratory values of a client who is taking spironolactone. Which of the following values should the nurse report to the provider?

• A. Sodium 144 mEq/L
• B. Potassium 5.2 mEq/L
• C. Bicarbonate 24 mEq/L
• D. Magnesium 1.9 mEq/L

Correct answer: B

Rationale: The correct answer is B: 'Potassium 5.2 mEq/L.' When a client is taking spironolactone, which is a potassium-sparing diuretic, monitoring potassium levels is crucial. A potassium level of 5.2 mEq/L is higher than normal and can lead to cardiac dysrhythmias, so it should be reported. Choices A, C, and D are within normal ranges and would not be of immediate concern when assessing a client taking spironolactone.

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