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. A client has deep vein thrombosis (DVT). Which of the following actions should the nurse take?

• A. Administer thrombolytics as prescribed.
• B. Massage the affected extremity every 2 hours.
• C. Apply warm compresses to the affected extremity.
• D. Place the client in a supine position with the legs elevated.

Correct answer: C

Rationale: The correct action for a nurse caring for a client with deep vein thrombosis (DVT) is to apply warm compresses to the affected extremity. Warm compresses help reduce swelling and pain in clients with DVT. Administering thrombolytics (Choice A) is not typically done without specific orders due to the risk of bleeding. Massaging the affected extremity (Choice B) can dislodge blood clots and lead to complications. Placing the client in a supine position with the legs elevated (Choice D) may increase the risk of clot dislodgment.

3. A client is receiving discharge teaching for a new prescription of warfarin. Which statement by the client indicates an understanding of the teaching?

• A. I will need to increase my intake of leafy green vegetables.
• B. I will avoid drinking grapefruit juice while taking warfarin.
• C. I will have my INR checked regularly.
• D. I will take my medication at the same time each day.

Correct answer: C

Rationale: The correct answer is C. Clients on warfarin therapy need to have their International Normalized Ratio (INR) checked regularly to monitor the medication's effectiveness and prevent complications like clotting or bleeding. Option A is incorrect because increasing leafy green vegetables can affect INR levels due to their vitamin K content. Option B is incorrect as grapefruit juice is not a significant concern with warfarin. Option D is important for medication adherence but does not specifically address the monitoring aspect required for warfarin therapy.

4. A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?

• A. Eat high-protein foods.
• B. Lie down after meals.
• C. Drink water with meals.
• D. Eat dry carbohydrates before getting out of bed.

Correct answer: D

Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.

5. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will check my blood glucose levels only when I feel sick.
• B. I will inject insulin in the same spot each time.
• C. I will rotate injection sites within the same anatomical region.
• D. I will inject insulin only if my blood glucose level is above 200 mg/dL.

Correct answer: C

Rationale: The correct answer is C. Clients with type 1 diabetes should rotate injection sites within the same anatomical region to prevent lipodystrophy. Choice A is incorrect because blood glucose levels should be checked regularly, not only when feeling sick. Choice B is incorrect as injecting insulin in the same spot each time can lead to lipodystrophy. Choice D is incorrect as insulin injections are usually required based on meal schedules and blood glucose levels, not just when levels are above 200 mg/dL.

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