Nursing Elites

1. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?

• A. Chest pain.
• B. Muscle spasms.
• C. Cool, moist skin.
• D. Incisional pain.

Correct answer: A

Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.

2. A nurse is caring for a client who has a pulmonary embolism. Which of the following findings indicates the effectiveness of the treatment?

• A. A chest x-ray reveals increased density in all lung fields.
• B. The client reports feeling less anxious.
• C. Diminished breath sounds are auscultated bilaterally.
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg.

Correct answer: B

Rationale: The correct answer is B. In a client with a pulmonary embolism, improvement in anxiety levels can indicate the effectiveness of treatment as it suggests better oxygenation and perfusion. Choices A, C, and D do not directly reflect the effectiveness of treatment for a pulmonary embolism. Increased density in all lung fields on a chest x-ray may indicate worsening of the condition, diminished breath sounds suggest impaired lung function, and ABG results with a pH of 7.48, PaO2 of 77 mm Hg, and PaCO2 of 47 mm Hg do not specifically indicate treatment effectiveness for a pulmonary embolism.

3. A nurse is providing teaching about newborn care to a group of parents. Which of the following instructions should the nurse include?

• A. You should not bathe your newborn every day.
• B. You should avoid covering your newborn with a heavy blanket during naps.
• C. You should expect your newborn's stools to be soft and yellow.
• D. You should keep your newborn's head elevated while they sleep.

Correct answer: D

Rationale: The correct answer is D: 'You should keep your newborn's head elevated while they sleep.' Keeping the newborn's head elevated while sleeping helps prevent conditions like sudden infant death syndrome (SIDS). Choice A is incorrect because newborns do not need to be bathed every day; it is recommended to bathe them 2-3 times a week. Choice B is incorrect as heavy blankets can increase the risk of suffocation for newborns. Choice C is incorrect as newborn stools are typically soft and yellow in color, not firm and light brown.

4. A nurse is caring for a client who is 2 hours postoperative following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Chest tube drainage of 60 mL/hr
• B. Oxygen saturation of 95%
• C. Chest tube drainage of 120 mL/hr
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

5. A client is receiving warfarin for atrial fibrillation. Which of the following laboratory tests should the nurse expect to be ordered to monitor the effect of warfarin?

• A. Platelet count
• B. International normalized ratio (INR)
• C. Prothrombin time (PT)
• D. Partial thromboplastin time (PTT)

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). When a client is on warfarin therapy, the INR is monitored regularly to assess the anticoagulant effects of the medication. A therapeutic INR range for most indications is between 2.0 to 3.0. Choices A, C, and D are not typically used to monitor the effect of warfarin. Platelet count assesses the number of platelets in the blood, PT measures the clotting time of plasma, and PTT evaluates the intrinsic pathway of coagulation.

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