Nursing Elites

1. What is the most important assessment for a patient post-surgery?

• A. Monitor vital signs
• B. Check surgical site for bleeding
• C. Check for abnormal breath sounds
• D. Check skin color

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs provide crucial information about a patient's physiological status, helping detect early signs of complications such as shock, bleeding, or infection. Checking the surgical site for bleeding is important but falls secondary to monitoring vital signs, which give a broader overview of the patient's condition. Checking for abnormal breath sounds and skin color are also important assessments, but they are not as immediate and general as monitoring vital signs in detecting various post-surgical complications.

2. A healthcare provider is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which finding should the healthcare provider identify as a contraindication to the administration of clozapine?

• A. Heart rate 58/min.
• B. Fasting blood glucose 100 mg/dL.
• C. Hgb 14 g/dL.
• D. WBC count 2,900/mm3.

Correct answer: D

Rationale: The correct answer is D: a low WBC count. Clozapine can suppress bone marrow function, leading to a decreased white blood cell count. This condition, known as agranulocytosis, increases the risk of severe infections. Monitoring WBC counts is essential during clozapine therapy. Choices A, B, and C are within normal ranges and are not contraindications for administering clozapine.

3. A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?

• A. Bisacodyl 10 mg rectal suppository.
• B. Magnesium hydroxide 30 ml PO.
• C. Famotidine 20 mg PO.
• D. Loperamide 4 mg PO.

Correct answer: A

Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. Bisacodyl is a stimulant laxative that promotes bowel movement, which is appropriate for a postpartum client experiencing constipation. Magnesium hydroxide (choice B) is an antacid and not indicated for constipation. Famotidine (choice C) is an H2 receptor antagonist used for reducing stomach acid production, not for constipation. Loperamide (choice D) is an antidiarrheal agent and would worsen constipation in this case.

4. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

5. What is the most important nursing action for a patient presenting with confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological assessment

Correct answer: A

Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.

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