Nursing Elites

1. A client is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Temperature of 37.1°C (98.8°F)
• C. Serosanguineous wound drainage
• D. Urine output of 25 mL/hr

Correct answer: D

Rationale: A urine output of 25 mL/hr is a sign of oliguria, which may indicate dehydration or kidney impairment and should be reported. A heart rate of 90/min is within the normal range (60-100/min) for adults at rest and may be expected postoperatively. A temperature of 37.1°C (98.8°F) is within the normal range (36.1-37.2°C or 97-99°F) and does not indicate an immediate concern. Serosanguineous wound drainage is a common finding postoperatively and indicates a normal healing process.

2. A nurse is caring for a client who is in labor and is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

• A. Fetal hypoxia
• B. Head compression
• C. Placenta previa
• D. Umbilical cord prolapse

Correct answer: B

Rationale: In the scenario of early decelerations noted during labor with electronic fetal monitoring, the nurse should expect head compression. Early decelerations are a normal response to fetal head compression during contractions and are not indicative of fetal distress. Choice A, fetal hypoxia, is incorrect as early decelerations are not associated with fetal oxygen deprivation. Choices C and D, placenta previa and umbilical cord prolapse, are unrelated to the scenario described and do not cause early decelerations.

3. A client with asthma is prescribed a corticosteroid inhaler. Which of the following instructions should the nurse include?

• A. Use the inhaler as needed for acute symptoms.
• B. Rinse the mouth after each use.
• C. Take the medication only during asthma attacks.
• D. Administer a bronchodilator after using the corticosteroid.

Correct answer: B

Rationale: The correct instruction is to rinse the mouth after each use of a corticosteroid inhaler to prevent oral candidiasis (thrush). Choice A is incorrect because corticosteroid inhalers are usually used on a regular schedule to control asthma symptoms, not just for acute symptoms. Choice C is incorrect as corticosteroid inhalers are typically used for long-term management, not just during asthma attacks. Choice D is incorrect as administering a bronchodilator after using a corticosteroid is not a standard practice and is not necessary for the effectiveness of the corticosteroid inhaler.

4. Which medication is commonly prescribed for a patient with hypertension?

• A. Lisinopril
• B. Metformin
• C. Atorvastatin
• D. Aspirin

Correct answer: A

Rationale: The correct answer is Lisinopril. Lisinopril is an ACE inhibitor commonly prescribed to patients with hypertension to manage their blood pressure. Metformin is used to treat type 2 diabetes, not hypertension (choice B). Atorvastatin is a statin used to lower cholesterol levels, not primarily prescribed for hypertension (choice C). Aspirin is used for its antiplatelet effects and in preventing cardiovascular events, but it is not a first-line treatment for hypertension (choice D). Therefore, Lisinopril is the most suitable choice for a patient with hypertension.

5. 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.

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