Nursing Elites

1. What is the most important nursing assessment post-surgery?

• A. Monitor vital signs
• B. Monitor blood pressure
• C. Monitor the surgical site
• D. Monitor the incision site

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.

2. What is the priority nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Perform a neurological exam

Correct answer: A

Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.

3. What is the appropriate intervention for a patient with hypertension refusing medication?

• A. Educate the patient on the importance of medication
• B. Respect the patient's decision
• C. Inform the healthcare provider
• D. Explore alternative treatment options

Correct answer: A

Rationale: The correct answer is A: Educate the patient on the importance of medication. Providing education to the patient is crucial in promoting understanding of the condition and the necessity of medication. By enhancing the patient's knowledge, healthcare providers can empower them to make informed decisions regarding their health. Choice B, respecting the patient's decision, may not be appropriate in this scenario as untreated hypertension can lead to serious complications. Choice C, informing the healthcare provider, is important but should be done after attempting to educate the patient. Choice D, exploring alternative treatment options, may be considered if the patient has concerns or side effects related to the medication, but initially, educating the patient about the importance of medication is key.

4. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 92%
• B. Use of pursed-lip breathing
• C. Increased anterior-posterior chest diameter
• D. Productive cough with green sputum

Correct answer: D

Rationale: The correct answer is D. A productive cough with green sputum can indicate a bacterial infection, which is a concern for clients with COPD. Reporting this finding to the provider is important for further evaluation and management. Choices A, B, and C are not as concerning in the context of COPD management. An oxygen saturation of 92% is within an acceptable range for COPD patients, pursed-lip breathing is a helpful technique for managing breathing difficulties in COPD, and an increased anterior-posterior chest diameter is a common finding in clients with COPD due to chronic air trapping.

5. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Fetal heart rate of 110/min
• B. 1+ pitting edema
• C. Blood pressure 138/80 mm Hg
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.

Similar Questions