Nursing Elites

1. A nurse is reviewing the medical record of a client who is 24 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min
• B. Serosanguineous drainage in the surgical drain
• C. Temperature 38.6°C (101.5°F)
• D. Urinary output 60 mL/hr

Correct answer: C

Rationale: The correct answer is C. A temperature of 38.6°C (101.5°F) is above the normal range and indicates a fever, which is a concerning finding postoperatively. Fever can be a sign of infection, so the nurse should report this finding to the provider for further evaluation and intervention. Choices A, B, and D are within expected parameters for a client who is 24 hours postoperative following abdominal surgery and do not require immediate reporting. A heart rate of 90/min, serosanguineous drainage in the surgical drain, and a urinary output of 60 mL/hr are all common postoperative findings that do not raise immediate concerns.

2. How should fluid balance in a patient with heart failure be monitored?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

3. A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?

• A. Position the client with the affected extremity higher than the heart
• B. Administration of acetaminophen
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.

4. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include?

• A. Critical pathways have unlimited timeframes for completion.
• B. Critical pathways are designed to decrease health care costs.
• C. Patients follow the critical pathway if variances occur.
• D. Budgets are used to create the critical pathway.

Correct answer: B

Rationale: The correct answer is B. Critical pathways are structured, multi-disciplinary plans of care designed to decrease health care costs and improve outcomes by standardizing and streamlining processes. Choice A is incorrect because critical pathways have specific timeframes for completion. Choice C is incorrect as patients are expected to follow the critical pathway without deviations to achieve optimal outcomes. Choice D is incorrect because budgets do not create critical pathways; rather, they are based on clinical guidelines and best practices.

5. A nurse is assessing a client who has hypovolemia. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Tachycardia.
• C. Increased blood pressure.
• D. Bounding pulse.

Correct answer: B

Rationale: The correct answer is B: Tachycardia. In hypovolemia, the body responds to decreased fluid volume by increasing the heart rate (tachycardia) to maintain adequate circulation. Bradycardia (Choice A) is not expected in hypovolemia since the heart rate typically increases to compensate for the reduced blood volume. Increased blood pressure (Choice C) is unlikely in hypovolemia as the decreased fluid volume leads to decreased pressure. A bounding pulse (Choice D) is more associated with conditions like hyperthyroidism or fever, not specifically with hypovolemia.

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