Nursing Elites

1. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

• A. Force oral fluids
• B. Request a nutrition consult
• C. Initiate contact precautions
• D. Limit visitors to immediate family only

Correct answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

2. An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?

• A. Blood clots
• B. Ecchymotic areas
• C. Jaundice
• D. Infection

Correct answer: B

Rationale: A coagulation time of 20 minutes is prolonged, suggesting a potential bleeding disorder. Ecchymotic areas, which are areas of bruising, are common signs of abnormal bleeding. Therefore, the nurse should observe the client for ecchymotic areas to monitor for potential bleeding issues. Blood clots are not typically associated with prolonged coagulation time but rather with excessive clotting. Jaundice is related to liver dysfunction, and infection is not directly linked to coagulation time.

3. A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?

• A. The client reports pain at the IV site
• B. The client’s blood pressure is elevated
• C. The client has swelling at the IV site
• D. The client’s heart rate is irregular

Correct answer: C

Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.

4. A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's blood pressure is 130/80 mm Hg.
• B. The client gains 1 kg in 24 hours.
• C. The client's potassium level is 5.5 mEq/L.
• D. The client's weight decreases by 0.5 kg in 24 hours.

Correct answer: C

Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.

5. When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?

• A. Position the client supine for a few minutes
• B. Assist the client to stand at the bedside
• C. Apply the blood pressure cuff securely
• D. Record the client’s pulse rate and rhythm

Correct answer: A

Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.

Similar Questions