Nursing Elites

1. The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Oxygen saturation of 92%.
• C. Temperature of 99°F (37.2°C).
• D. Pain at the surgical site.

Correct answer: C

Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.

2. The client with congestive heart failure (CHF) is receiving discharge instructions. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself daily and report a weight gain of more than 2 pounds in 24 hours.
• B. I will take my diuretic medication in the morning.
• C. I will call my healthcare provider if I experience increased shortness of breath.
• D. I will drink at least 3 liters of fluid each day.

Correct answer: D

Rationale: The correct answer is D. Drinking at least 3 liters of fluid each day may be contraindicated for a client with CHF due to the risk of fluid overload. This can exacerbate heart failure symptoms and lead to complications. Options A, B, and C are all appropriate statements that demonstrate understanding of managing CHF and seeking appropriate medical attention when needed.

3. The client is receiving warfarin (Coumadin) therapy. Which statement by the client indicates a need for further teaching?

• A. I will avoid eating foods high in vitamin K.
• B. I will use a soft toothbrush and an electric razor.
• C. I will keep all appointments for blood tests.
• D. I will avoid participating in contact sports.

Correct answer: D

Rationale: The correct answer is D because participating in contact sports can increase the risk of injury and bleeding in a client receiving warfarin therapy. Warfarin is a blood thinner, and activities with a higher risk of injury should be avoided to prevent bleeding complications. Choices A, B, and C are all correct statements for a client on warfarin therapy. Avoiding foods high in vitamin K helps maintain consistent anticoagulation levels, using a soft toothbrush and an electric razor reduces the risk of bleeding gums and cuts, and keeping appointments for blood tests ensures proper monitoring of the client's international normalized ratio (INR) levels.

4. A school nurse is developing a program to address bullying among students. Which component is most important to include?

• A. education on the effects of bullying
• B. training for teachers on how to handle bullying incidents
• C. a peer mentoring program
• D. a zero-tolerance policy for bullying

Correct answer: B

Rationale: Training for teachers is the most important component to include in addressing bullying among students. Teachers play a crucial role in identifying, intervening, and preventing bullying incidents. By providing teachers with training on how to handle bullying, they can effectively address such situations, support victims, and educate students on appropriate behavior. While education on the effects of bullying (Choice A) is important, teachers need practical skills to intervene. Peer mentoring programs (Choice C) and zero-tolerance policies (Choice D) are valuable but may not be as effective without teachers being equipped to address bullying incidents directly.

5. The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?

• A. I will increase my intake of vitamin C.
• B. I will avoid alcohol and tobacco.
• C. I will need to take folic acid supplements.
• D. I will avoid taking any medication without consulting my healthcare provider.

Correct answer: D

Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy. Increasing intake of vitamin C (Choice A) is beneficial but does not address medication safety. Avoiding alcohol and tobacco (Choice B) is essential, but the question focuses on medication safety. Taking folic acid supplements (Choice C) is vital for neural tube development but does not cover the broader topic of medication safety.

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