Nursing Elites

1. A nurse is providing discharge teaching to a client following a cholecystectomy. Which of the following instructions should the nurse include?

• A. I should avoid lifting objects heavier than 5 pounds for 1 week.
• B. I can resume my usual activities after 2 weeks.
• C. I should expect to have pain in my right shoulder.
• D. I should follow a low-protein diet for 1 week.

Correct answer: C

Rationale: The correct answer is C. Pain in the right shoulder after a cholecystectomy is common due to residual gas from the procedure. Choices A, B, and D are incorrect. It is important to avoid heavy lifting for a longer period than just 1 week to prevent complications. Resuming usual activities after 2 weeks may not be appropriate depending on the individual's recovery. Following a low-protein diet is not a standard recommendation post-cholecystectomy.

2. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?

• A. Serum potassium
• B. Platelets
• C. aPTT
• D. INR

Correct answer: C

Rationale: The correct answer is C: aPTT. Monitoring the activated partial thromboplastin time (aPTT) is crucial when a client is receiving heparin therapy. The aPTT reflects the clotting time and helps assess the effectiveness of heparin in preventing clot formation. Keeping the aPTT within the therapeutic range ensures that the medication is working optimally. Choices A, B, and D are incorrect because serum potassium, platelets, and INR are not direct indicators of heparin's effectiveness or therapeutic range.

3. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following activities should the toddler participate?

• A. Looking at alphabet flashcards
• B. Playing with a large plastic truck
• C. Using scissors to cut out paper shapes
• D. Watching a cartoon in the dayroom

Correct answer: B

Rationale: The correct answer is playing with a large plastic truck. This activity is suitable for toddlers as it promotes their development, encourages fine motor skills, and provides an opportunity for imaginative play. Looking at alphabet flashcards may be more suitable for older children who are learning letters and words. Using scissors to cut out paper shapes may pose a safety risk for a toddler, as they may not have the dexterity or understanding required for this activity. Watching a cartoon in the dayroom is a passive activity and does not actively engage the toddler in physical or cognitive development.

4. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following findings should the nurse expect?

• A. Polyuria
• B. Warm, dry skin
• C. Irritability
• D. Hyperventilation

Correct answer: C

Rationale: Irritability is a common finding in clients with hypoglycemia due to decreased glucose levels in the brain. Polyuria (excessive urination) is not typically associated with hypoglycemia, but rather with hyperglycemia. Warm, dry skin is not a typical finding in hypoglycemia; instead, the skin may be cool and clammy. Hyperventilation is not a common finding in hypoglycemia; instead, shallow breathing or difficulty breathing may occur.

5. A nurse is caring for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 120/80 mm Hg
• B. Weight gain of 0.9 kg (2 lb) in 1 week
• C. Urine output of 30 mL/hr
• D. Respiratory rate 16/min

Correct answer: B

Rationale: A weight gain of 0.9 kg (2 lb) in 1 week is an indication of fluid retention, which is concerning in a client with preeclampsia. This can be a sign of worsening condition requiring immediate medical attention. High blood pressure (option A) is expected in preeclampsia, a urine output of 30 mL/hr (option C) is decreased but not as urgent as the weight gain in this scenario, and a respiratory rate of 16/min (option D) is within normal limits.

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