Nursing Elites

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

• A. Heart rate of 80/min
• B. Sanguineous drainage on the surgical dressing
• C. Temperature of 37.5°C (99.5°F)
• D. Serous drainage on the surgical dressing

Correct answer: B

Rationale: Sanguineous drainage from the surgical site 48 hours after surgery could indicate a complication such as hemorrhage or infection and should be reported. Sanguineous drainage is typically seen in the early postoperative period due to the presence of blood. Serous drainage, on the other hand, is normal in the later stages of wound healing. A heart rate of 80/min is within the normal range for an adult. A temperature of 37.5°C (99.5°F) is slightly elevated but not a concerning finding in the absence of other symptoms.

2. A client is receiving heparin therapy. Which of the following laboratory results indicates the client is receiving an effective dose of heparin?

• A. INR 1.5
• B. aPTT 60 seconds
• C. Platelets 150,000/mm³
• D. Potassium 4.0 mEq/L

Correct answer: B

Rationale: An aPTT of 60 seconds indicates the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for a clot to form, and a therapeutic range for heparin therapy is usually 1.5 to 2 times the control value, which is around 60-80 seconds. An INR of 1.5 is not related to heparin therapy, as it is commonly used to monitor warfarin therapy. Platelet count and potassium levels are not direct indicators of the effectiveness of heparin therapy.

3. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Keep the head of the bed elevated to 15 degrees.
• B. Change the feeding bag every 48 hours.
• C. Administer the feeding through a large-bore syringe.
• D. Flush the tube with 0.9% sodium chloride every 4 hours.

Correct answer: D

Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.

4. A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose of 110 mg/dL.
• B. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
• C. WBC count of 6,500/mm3.
• D. Temperature of 37.3°C (99.1°F).

Correct answer: B

Rationale: A weight loss of 0.5 kg (1.1 lb) in 24 hours may indicate dehydration or malnutrition, which are critical concerns for a client receiving total parenteral nutrition (TPN). Therefore, the nurse should report this finding to the provider. Elevated blood glucose levels (Choice A) can be managed by adjusting TPN components, WBC count (Choice C) and a slightly elevated temperature (Choice D) are not directly related to TPN administration and may not require immediate intervention.

5. A nurse is assessing a newborn who was delivered at 32 weeks of gestation. Which of the following findings should the nurse expect?

• A. Dry, cracked skin.
• B. Lanugo covering the skin.
• C. Vernix caseosa covering the skin.
• D. Creases covering the soles of the feet.

Correct answer: B

Rationale: The correct answer is B: Lanugo covering the skin. Lanugo, a fine downy hair, is a common finding in newborns delivered prematurely at 32 weeks gestation. Choice A (Dry, cracked skin) is incorrect as premature infants often have translucent and delicate skin. Choice C (Vernix caseosa covering the skin) is incorrect as vernix, a waxy substance, is more commonly seen in full-term newborns. Choice D (Creases covering the soles of the feet) is incorrect as creases on the soles of the feet are a normal finding in term newborns, not specifically related to prematurity.

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