Nursing Elites

1. What are the signs of infection that should be monitored in a postoperative patient?

• A. Fever and chills
• B. All of the above
• C. Increased pain or tenderness
• D. Redness, swelling, and warmth at the surgical site

Correct answer: D

Rationale: The correct answer is D: 'Redness, swelling, and warmth at the surgical site.' These are specific signs of infection at the surgical site that a nurse should monitor for in a postoperative patient. While fever, chills, and increased pain can also indicate infection, the most direct signs are redness, swelling, and warmth at the surgical site. Therefore, 'D' is the best choice as it directly relates to the site of the surgery and is crucial to monitor for potential postoperative infections.

2. What is the priority action for a patient with a fever?

• A. Administer an antipyretic medication as prescribed.
• B. Assess the patient's temperature regularly.
• C. Provide cooling measures such as a cool compress.
• D. Provide the patient with blankets for comfort.

Correct answer: B

Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.

3. A healthcare provider is caring for a client who has heart failure and is prescribed enalapril. The provider should monitor the client for which of the following adverse effects?

• A. Hypertension
• B. Hypokalemia
• C. Hyperglycemia
• D. Hyperkalemia

Correct answer: D

Rationale: Corrected Question: When a client with heart failure is prescribed enalapril, monitoring for hyperkalemia is essential. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can lead to an increase in potassium levels in the blood. This adverse effect can be serious and potentially life-threatening. Choices A, B, and C are incorrect because enalapril does not typically cause hypertension, hypokalemia, or hyperglycemia as adverse effects. It's essential for healthcare providers to be vigilant in monitoring potassium levels when clients are on ACE inhibitors like enalapril.

4. A school nurse is developing a teaching plan about testicular cancer for a group of clients. Which of the following information should the nurse include in the teaching?

• A. Perform a testicular self-examination weekly.
• B. Do not palpate the epididymis when performing a testicular self-examination.
• C. Expect testicles to be uniform in consistency when performing a testicular self-examination.
• D. Perform a testicular self-examination after a cool shower.

Correct answer: C

Rationale: The correct answer is C because testicles should be uniform in consistency when performing a self-exam, and any lumps or abnormalities should be reported. Choice A is incorrect as testicular self-examinations should be performed monthly, not weekly. Choice B is incorrect because the epididymis should be included in the examination. Choice D is incorrect because a warm shower helps relax the scrotum, making the exam easier to perform.

5. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery. What is the nurse's priority action to prevent complications?

• A. Encourage the patient to perform incentive spirometry.
• B. Assist the patient in ambulating around the unit.
• C. Reposition the patient every 2 hours.
• D. Administer pain medication as prescribed.

Correct answer: A

Rationale: The correct answer is to encourage the patient to perform incentive spirometry. Incentive spirometry helps prevent respiratory complications, such as atelectasis, by promoting deep breathing and optimal lung expansion. Ambulating, repositioning, and administering pain medication are important interventions but do not take precedence over preventing respiratory complications in the immediate postoperative period.

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