Nursing Elites

1. A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Temperature of 37.8°C (100°F).
• C. Urine output of 75 mL in the past 4 hours.
• D. WBC count of 15,000/mm³.

Correct answer: D

Rationale: The correct answer is D. An elevated WBC count can indicate a potential infection, especially in a postoperative client. This finding should be reported to the provider for further evaluation and management. Choices A, B, and C are common occurrences in postoperative clients and may not necessarily indicate a severe issue. Serosanguineous drainage on the surgical dressing is a normal finding in the immediate postoperative period. A temperature of 37.8°C (100°F) can be a mild fever, which is common postoperatively due to the body's response to tissue injury. Urine output of 75 mL in the past 4 hours may be within normal limits for a postoperative client, especially if they are still recovering from anesthesia.

2. A nurse is caring for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the NG tube with 0.9% sodium chloride before feedings.
• B. Place the client in a high Fowler's position during feedings.
• C. Administer the feedings over 30 minutes.
• D. Warm the formula before administering it.

Correct answer: B

Rationale: The correct answer is to place the client in a high Fowler's position during enteral feedings. This position helps prevent aspiration by promoting the downward flow of the feeding and reducing the risk of regurgitation into the lungs. Choice A is incorrect because flushing the NG tube with 0.9% sodium chloride before feedings is not directly related to preventing aspiration. Choice C is incorrect because the rate of administration does not directly impact the risk of aspiration. Choice D is incorrect because warming the formula does not specifically address the prevention of aspiration during enteral feedings.

3. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. What dietary instruction should the nurse provide?

• A. Take magnesium hydroxide for indigestion.
• B. Drink at least 3L of fluid daily.
• C. Eat 1g/kg of protein per day.
• D. Consume foods high in potassium.

Correct answer: C

Rationale: For a client with chronic kidney disease receiving hemodialysis, consuming 1g/kg of protein per day is important. This amount helps manage the condition without overburdening the kidneys. Choice A is incorrect because magnesium hydroxide is not specifically recommended for clients with chronic kidney disease. Choice B is not accurate as fluid intake needs to be individualized based on the client's condition and dialysis status. Choice D is incorrect because foods high in potassium should generally be limited for individuals with kidney disease undergoing hemodialysis to prevent hyperkalemia.

4. A nurse is reviewing the facility's safety protocols concerning newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?

• A. Staff will apply the identification band after the first bath.
• B. I will not make public announcements about my baby's birth.
• C. I can remove my baby's identification band as long as they are in my room.
• D. I can leave my baby in my room while walking in the hallway.

Correct answer: B

Rationale: The correct answer is B. Not making public announcements about the baby's birth is crucial in preventing newborn abduction as it avoids exposing personal information. Choice A is incorrect because the identification band should be applied immediately after birth, not after the first bath. Choice C is incorrect as the baby's identification band should never be removed by the parent. Choice D is incorrect as parents should not leave their baby unattended in the room while they are outside the room.

5. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?

• A. Frothy, pink sputum
• B. Jugular vein distention
• C. Weight gain
• D. Bradypnea

Correct answer: A

Rationale: Correct! Frothy, pink sputum is a classic sign of pulmonary congestion in left-sided heart failure. This occurs due to the accumulation of fluid in the lungs, leading to the coughing up of frothy, pink-tinged sputum. Jugular vein distention (choice B) is more indicative of right-sided heart failure, where fluid backs up into the systemic circulation. Weight gain (choice C) may occur due to fluid retention, but it is not a direct manifestation of pulmonary congestion. Bradypnea (choice D) refers to abnormally slow breathing and is not specifically associated with pulmonary congestion.

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