Nursing Elites

1. A client who is post-op day 1 after abdominal surgery reports pain at the incision site. The nurse notes the presence of a small amount of serosanguineous drainage. What is the most appropriate nursing action?

• A. Apply a sterile dressing to the incision.
• B. Reinforce the dressing and document the findings.
• C. Remove the dressing and assess the incision site.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: The correct answer is to reinforce the dressing and document the findings. It is important to monitor the incision site closely after surgery, especially when there is a small amount of serosanguineous drainage. Reinforcing the dressing helps maintain cleanliness and pressure on the wound. Documenting the findings is crucial for tracking the client's progress and alerting healthcare providers if necessary. Applying a sterile dressing (Choice A) may not be needed if the current dressing is intact. Removing the dressing (Choice C) can increase the risk of contamination. Notifying the healthcare provider (Choice D) is not the first step for minor drainage on post-op day 1.

2. A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide?

• A. Oatmeal cookies
• B. Cheese sticks
• C. Yogurt
• D. Apple slices

Correct answer: A

Rationale: Oatmeal cookies are the best snack suggestion for a preschooler with constipation needing to increase fiber intake. Oatmeal is high in fiber, which helps relieve constipation. Cheese sticks, yogurt, and apple slices are not as high in fiber content as oatmeal and may not be as effective in addressing the constipation issue in this scenario.

3. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

• A. Respiratory apnea of 30 seconds
• B. Oxygen saturation rate of 88%
• C. Eight premature ventricular beats every minute
• D. Disconnected monitor signal for the last 6 minutes.

Correct answer: A

Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.

4. A client with atrial fibrillation is receiving digoxin (Lanoxin) and warfarin (Coumadin). Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Heart rate of 58 beats per minute
• B. Presence of a new murmur
• C. INR of 2.5
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. The presence of a new murmur in a client with atrial fibrillation may indicate a valvular problem or other complications, requiring immediate reporting. A heart rate of 58 beats per minute is within the normal range for some individuals with atrial fibrillation, so it is not an immediate concern. An INR of 2.5 is within the therapeutic range for a client on warfarin, indicating appropriate anticoagulation. A blood pressure of 110/70 mmHg is also within the normal range and does not pose an immediate threat to the client's health.

5. The practical nurse (PN) is assigned to work with three registered nurses (RNs) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

• A. Diabetic ketoacidosis with a Glasgow Coma Scale score change from 10 to 7.
• B. Myxedema coma with a blood pressure change from 80/50 to 70/40.
• C. Viral meningitis with a temperature change from 101°F to 102°F.
• D. Subdural hematoma with a blood pressure change from 150/80 to 170/60.

Correct answer: C

Rationale: The client with viral meningitis and a temperature change is the most stable and appropriate for assignment to the PN. A change in temperature from 101°F to 102°F is not as critical as changes in Glasgow Coma Scale score, blood pressure, or wider blood pressure variations. The other clients require more complex monitoring and intervention due to their critical changes in status.

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