Nursing Elites

1. What is the most important assessment for a patient post-op to monitor for complications?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood glucose levels
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.

2. A nurse is assessing a client who is 1 hour postoperative following a hysterectomy. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min.
• B. Blood pressure of 120/80 mm Hg.
• C. Oxygen saturation of 94%.
• D. Respiratory rate of 16/min.

Correct answer: A

Rationale: A heart rate of 78/min is within the normal range; however, postoperative patients require close monitoring for any signs of complications. While the heart rate is normal, other critical findings such as increased pain, excessive bleeding, or other concerning symptoms may need immediate attention. Choices B, C, and D all indicate normal postoperative vital signs and oxygen saturation levels, which do not raise immediate concerns requiring reporting to the provider.

3. A client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the hip?

• A. Position the client's legs in adduction
• B. Place a pillow between the client's legs when turning
• C. Keep the client in a low Fowler's position
• D. Turn the client onto the affected side

Correct answer: B

Rationale: Placing a pillow between the client's legs when turning is essential to prevent hip dislocation post hip replacement surgery. This action helps maintain proper alignment of the hip joint and prevents adduction, which can lead to dislocation. Positioning the client's legs in adduction (choice A) can increase the risk of hip dislocation. Keeping the client in a low Fowler's position (choice C) or turning the client onto the affected side (choice D) does not directly address hip dislocation prevention.

4. A nurse is reviewing the laboratory results of a client who has Cushing's disease. The nurse should expect an increase in which of the following laboratory values?

• A. Serum glucose level
• B. Serum potassium level
• C. Serum calcium level
• D. Serum sodium level

Correct answer: A

Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, there is increased cortisol production, leading to elevated blood glucose levels. This occurs due to the role of cortisol in promoting gluconeogenesis and insulin resistance. Choices B, C, and D are incorrect because Cushing's disease is not typically associated with alterations in serum potassium, calcium, or sodium levels.

5. A client who is 1 day postpartum plans to breastfeed. Which statement indicates an understanding of the teaching provided by the nurse?

• A. I will breastfeed every 4 hours.
• B. I will feed my baby from each breast for 5 minutes.
• C. I will use both breasts at each feeding.
• D. I will pump my breasts if my baby does not wake up to feed.

Correct answer: C

Rationale: The correct answer is C. Using both breasts at each feeding helps ensure adequate milk production and consumption. Option A is incorrect because breastfeeding should be done on demand rather than following a strict schedule. Option B is incorrect as limiting feeding time to 5 minutes per breast may not provide the baby with enough milk. Option D is also incorrect as pumping should not replace direct breastfeeding unless there is a specific medical reason to do so.

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