Nursing Elites

1. A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following statements should the nurse include?

• A. You should avoid drinking alcohol while taking this medication.
• B. You should monitor for signs of infection.
• C. Take this medication with food to prevent gastrointestinal upset.
• D. Take this medication with a full glass of water.

Correct answer: B

Rationale: The correct statement the nurse should include when teaching a client taking clopidogrel is to monitor for signs of infection. Clopidogrel affects platelet levels and can increase the risk of bleeding. Monitoring for signs of infection is crucial because a compromised immune system can make the client more susceptible to infections. Choices A, C, and D are incorrect because clopidogrel is not directly linked to alcohol restrictions, food requirements, or specific water intake instructions.

2. A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings is a priority for the nurse to report?

• A. Low back pain
• B. Tachycardia
• C. Flushed skin
• D. Headache

Correct answer: B

Rationale: The correct answer is B: Tachycardia. Tachycardia can indicate a hemolytic transfusion reaction, a severe and life-threatening complication of blood transfusion. The nurse should report tachycardia immediately to prevent further complications. Low back pain, flushed skin, and headache are also important to monitor during a blood transfusion, but they are not as indicative of a severe transfusion reaction as tachycardia.

3. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Heart rate of 88/min.
• C. Blood pressure of 118/76 mm Hg.
• D. Temperature of 38.8°C (101.8°F).

Correct answer: D

Rationale: A temperature of 38.8°C (101.8°F) is above the normal range and may indicate infection, which should be reported. Elevated temperature postoperatively can be a sign of infection, especially in the early postoperative period. Serosanguineous drainage on the surgical dressing is expected in the early postoperative period. A heart rate of 88/min and a blood pressure of 118/76 mm Hg are within normal ranges and do not necessarily indicate a complication postoperatively.

4. A patient is 1 day postoperative following a hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the hip?

• A. Keep the patient in a side-lying position.
• B. Place a pillow between the patient's legs.
• C. Instruct the patient to avoid sitting for long periods.
• D. Elevate the head of the bed to 90 degrees.

Correct answer: B

Rationale: Placing a pillow between the patient's legs is the correct action to prevent dislocation of the hip following arthroplasty. This technique helps maintain proper alignment and stability of the hip joint. Keeping the patient in a side-lying position may not provide the necessary support to prevent hip dislocation. Instructing the patient to avoid sitting for long periods is important for preventing complications like deep vein thrombosis but does not directly prevent hip dislocation. Elevating the head of the bed to 90 degrees is not relevant to preventing hip dislocation in a postoperative hip arthroplasty patient.

5. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Polyuria
• C. Hypertension
• D. Weight loss

Correct answer: B

Rationale: Polyuria is the correct answer. Diabetes insipidus is characterized by the inability to concentrate urine, leading to excessive urination (polyuria) and thirst. Bradycardia (slow heart rate) is not typically associated with diabetes insipidus. While dehydration from the excessive urination can lead to hypotension rather than hypertension, and weight loss can occur due to fluid loss, the most specific and significant finding expected in diabetes insipidus is polyuria.

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