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 in a mental health unit is planning room assignments for four clients. Which of the following clients should be closest to the nurse's station?

• A. A client who has an anxiety disorder and is experiencing moderate anxiety.
• B. A client who has somatic symptom disorder and reports chronic pain.
• C. A client who has depressive disorder and reports feeling hopeless.
• D. A client who has bipolar disorder and impaired social interactions.

Correct answer: D

Rationale: A client with bipolar disorder and impaired social interactions should be placed closest to the nurse's station for closer monitoring. Clients with bipolar disorder may experience mood swings, including manic episodes that can lead to impulsive behaviors or aggression. Placing such a client near the nurse's station allows for quick intervention and monitoring of their social interactions, especially if they are impaired. The other options, such as anxiety disorder, somatic symptom disorder, and depressive disorder, do not inherently require immediate proximity to the nurse's station based on the information provided.

3. A nurse is assessing a client who has been taking lithium for bipolar disorder. Which of the following findings should the nurse report to the provider?

• A. Tremors
• B. Increased thirst
• C. Weight gain
• D. Diarrhea

Correct answer: A

Rationale: Corrected Rationale: Tremors can indicate lithium toxicity, which should be reported to the provider for further evaluation. Tremors are a significant sign of lithium toxicity and can lead to serious complications if not addressed promptly. Increased thirst, weight gain, and diarrhea are common side effects of lithium but are not typically indicative of toxicity. Therefore, the nurse should prioritize reporting tremors as it requires immediate attention.

4. A client with osteoporosis is being taught by a nurse about preventing bone loss. Which of the following instructions should the nurse include?

• A. Take a calcium supplement once a day.
• B. Avoid weight-bearing exercises.
• C. Walk for 30 minutes 3 times per week.
• D. Increase intake of high-phosphorus foods.

Correct answer: C

Rationale: The correct answer is C: 'Walk for 30 minutes 3 times per week.' Walking is a weight-bearing exercise that helps prevent bone loss and improve overall health in clients with osteoporosis. Option A is incorrect because while calcium is essential for bone health, simply taking a supplement is not sufficient for preventing bone loss. Option B is incorrect because weight-bearing exercises are actually beneficial for improving bone density and strength. Option D is incorrect because high-phosphorus foods do not play a significant role in preventing bone loss in osteoporosis.

5. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?

• A. Remove the client's restraint every 4 hours.
• B. Document the client's condition every 15 minutes.
• C. Attach the restraint to the bed's side rails.
• D. Request a PRN restraint prescription for clients who are aggressive.

Correct answer: B

Rationale: The correct answer is B. When updating protocols for the use of belt restraints, it is essential to document the client's condition every 15 minutes. This frequent documentation helps ensure the client's safety and allows for timely assessment of the need for continued restraint use. Choice A is incorrect because restraints should be removed and reassessed more frequently than every 4 hours. Choice C is incorrect as restraints should not be attached to the bed's side rails due to entrapment risks. Choice D is also incorrect as restraints should not be used as needed (PRN) but rather based on a specific prescription and assessment indicating the need for restraint use.

Similar Questions