Nursing Elites

1. A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 118/76 mm Hg
• B. Heart rate of 88/min
• C. Urinary output of 30 mL/hr
• D. Hematocrit 42%

Correct answer: B

Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.

2. A client at 14 weeks gestation reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?

• A. Describe your feelings to me about being pregnant.
• B. You should discuss your feelings with your provider.
• C. Have you discussed these feelings with your partner?
• D. When did you start having these feelings?

Correct answer: A

Rationale: The correct response is to use open-ended questions that allow the client to explore and express their feelings. Choice A encourages the client to describe their feelings, fostering open communication and providing an opportunity for the client to express themselves freely. Choices B and C do not directly address the client's feelings and may not promote open communication. Choice D focuses on the timing of the feelings rather than exploring the feelings themselves, making it a less therapeutic response.

3. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Serous drainage on the dressing
• C. Temperature 37.3°C (99.1°F)
• D. Calf pain on dorsiflexion

Correct answer: D

Rationale: The correct answer is D. Calf pain on dorsiflexion following knee surgery may indicate a complication such as deep vein thrombosis, which is a serious condition requiring medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal range for a client post knee surgery and do not typically indicate immediate complications that require urgent reporting.

4. A nurse is assessing a client who has hyperthyroidism. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Dry skin.
• C. Cold intolerance.
• D. Tachycardia.

Correct answer: D

Rationale: The correct answer is D: Tachycardia. In clients with hyperthyroidism, tachycardia is a common finding due to the increased metabolic rate. Weight loss and heat intolerance are also expected due to the elevated metabolism. Choices A, B, and C (Weight gain, dry skin, cold intolerance) are not typical findings in hyperthyroidism, as the condition is associated with an overactive thyroid gland leading to an increase in metabolic functions.

5. What is the appropriate intervention when a patient experiences a fall?

• A. Assess for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The appropriate intervention when a patient experiences a fall is to assess for injuries. This immediate action helps in identifying any harm or complications resulting from the fall, allowing for timely intervention. Calling for help may be necessary after assessing the injuries, but the priority is to evaluate the patient's condition. Documenting the fall is important for record-keeping purposes but should come after ensuring the patient's safety. Notifying the healthcare provider can be done once the assessment has been completed and any necessary initial interventions have been initiated.

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