Nursing Elites

1. Nurses caring for four clients. Which of the following client data should the nurse report to the provider?

• A. A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
• B. Client drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hours following surgery
• C. Client who is 4 hours postoperative and has a heart rate of 98 per minute
• D. The client has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

Correct answer: D

Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.

2. A client in active labor is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

• A. Contractions lasting 80 seconds.
• B. FHR baseline of 170/min.
• C. Early decelerations in the FHR.
• D. Temperature of 37.4°C (99.3°F).

Correct answer: B

Rationale: The correct answer is B because a baseline FHR of 170/min indicates fetal tachycardia, which needs further evaluation. Choice A about contractions lasting 80 seconds is within the normal range for active labor. Choice C, early decelerations in the FHR, are generally considered benign and do not require immediate reporting. Choice D, a temperature of 37.4°C (99.3°F), falls within normal limits for a laboring client and does not warrant immediate reporting.

3. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Massage the affected extremity to promote circulation.
• B. Elevate the affected extremity.
• C. Apply cold packs to the affected extremity.
• D. Perform range-of-motion exercises on the affected extremity.

Correct answer: C

Rationale: The correct intervention for a client with DVT is to apply cold packs to the affected extremity. Cold packs can help reduce swelling and pain by constricting blood vessels. Massaging the affected extremity can dislodge a clot and worsen the condition. Elevating the affected extremity helps with blood flow but is not the priority intervention for DVT. Performing range-of-motion exercises on the affected extremity can also dislodge a clot and is contraindicated.

4. A client with liver cirrhosis is experiencing confusion. Which of the following laboratory values should the nurse report to the provider?

• A. Bilirubin 0.8 mg/dL
• B. Ammonia 145 mcg/dL
• C. Albumin 4 g/dL
• D. Hemoglobin 13.5 g/dL

Correct answer: B

Rationale: The correct answer is B: Ammonia 145 mcg/dL. An elevated ammonia level can indicate hepatic encephalopathy in clients with liver cirrhosis, leading to confusion. Bilirubin (Choice A) is within the normal range, indicating adequate liver function. Albumin (Choice C) and Hemoglobin (Choice D) levels are also within normal limits and are not directly related to the client's confusion in this scenario.

5. A nurse is assessing a client who has a peripherally inserted central catheter (PICC). Which of the following findings should the nurse report to the provider?

• A. Redness at the insertion site.
• B. Swelling of the arm above the insertion site.
• C. A bruised area around the insertion site.
• D. A temperature of 37.2°C (99°F).

Correct answer: B

Rationale: Swelling of the arm above the insertion site is concerning as it can indicate complications like thrombosis, which require immediate attention. Redness at the insertion site is common and expected in the initial stages. A bruised area around the insertion site may result from the insertion procedure and is usually not alarming unless it worsens or becomes larger. A temperature of 37.2°C (99°F) is within the normal range and is not directly related to PICC complications.

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