Nursing Elites

1. A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?

• A. Notify the doctor
• B. Empty the drain
• C. Do nothing
• D. Remove the drain

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.

2. A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation (SAO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?

• A. tuberculosis (TB)
• B. pneumonia
• C. pleural effusion
• D. hypoxia

Correct answer: D

Rationale: A combined low PO2 and low SAO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation, but the best analysis in this case is hypoxia due to the combination of low PO2 and low SAO2.

3. During a petit mal seizure in the clinic, what should be the highest priority?

• A. Provide a safe environment free of obstructions in the immediate area
• B. Call a code
• C. Contact the patient's physician
• D. Prevent excessive movement of the extremities

Correct answer: A

Rationale: During a petit mal seizure, the highest priority is to provide a safe environment free of obstructions in the immediate area. This action aims to prevent injuries to the patient during the seizure. While calling a code or contacting the patient's physician may be necessary at some point, immediate safety measures take precedence. Preventing excessive movement of the extremities is relevant but ensuring a safe environment is crucial to avoid harm during the seizure.

4. A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client?

• A. "You should discuss the inheritance risk with your physician."?
• B. "Sickle cell disease is genetically based and might be passed on to children."?
• C. "Sickle cell disease is genetically based and is not passed on to children."?
• D. "Sickle cell disease is caused by an infection and cannot be passed on to children."?

Correct answer: B

Rationale: A client with sickle cell disease has a genetic condition that can be passed on to their offspring. The most appropriate statement for the PN to provide is to acknowledge this fact and inform the client that sickle cell disease is genetically based and might be passed on to children. This empowers the client with accurate information. Choice A has been refined to emphasize discussing the inheritance risk, making it a better option than the vague original choice. Choices C and D provide incorrect information. Sickle cell disease is indeed genetically based and can be inherited.

5. When encountering the significant other of a patient with end-stage AIDS crying during her smoke break, what is the most appropriate action for the nurse to take?

• A. Allow her to grieve by herself.
• B. Tell her to go ahead and cry, after all, your husband’s pretty bad off.
• C. Tell her you realize how upset she is, but you don’t want to talk about it now.
• D. Approach her, offering tissues, and encourage her to verbalize her feelings

Correct answer: D

Rationale: Approaching the significant other, offering tissues, and encouraging her to verbalize her feelings is the most appropriate action for the nurse to take. Being left alone during the grief process isolates individuals, and they need an outlet for their feelings. By showing empathy and providing support, the nurse can help the significant other cope with her emotions. Choices A, B, and C are inappropriate because they do not offer support or encourage the expression of feelings, which are crucial in such situations.

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