Nursing Elites

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

• A. Heart rate of 90/min
• B. Capillary refill of 2 seconds
• C. Wound drainage of 30 mL in 8 hours
• D. Warmth and redness in the calf

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

2. What is the best way to monitor for infection in a patient with a central line?

• A. Check the central line site daily
• B. Monitor the patient's vital signs
• C. Check the central line dressing every other day
• D. Check for signs of sepsis

Correct answer: A

Rationale: The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.

3. How should a healthcare provider manage a patient with chronic kidney disease?

• A. Limit fluid intake
• B. Increase potassium intake
• C. Provide a high-protein diet
• D. Administer IV antibiotics

Correct answer: A

Rationale: Limiting fluid intake is essential in managing patients with chronic kidney disease to prevent fluid overload, which can worsen kidney function. Increasing potassium intake is not recommended as patients with kidney disease often need to limit potassium. Providing a high-protein diet may put extra strain on the kidneys, so it is not ideal. Administering IV antibiotics is not a standard treatment for chronic kidney disease.

4. A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client's fluid intake to 1500 mL per day
• B. Avoid massaging the affected extremity to relieve pain
• C. Avoid applying cold packs to the client's affected extremity
• D. Elevate the client's affected extremity when in bed

Correct answer: D

Rationale: The correct instruction for a client with DVT is to elevate the affected extremity when in bed. Elevation helps reduce swelling by promoting venous return. Limiting fluid intake could lead to dehydration and is not recommended. Massaging the affected extremity can dislodge a clot, leading to serious complications. Applying cold packs can cause vasoconstriction and should be avoided in DVT.

5. A nurse is teaching a client about home care following cataract surgery. Which of the following statements should the nurse include?

• A. You should wear a protective eye shield while sleeping.
• B. You should avoid bending over to pick things up.
• C. You should apply pressure to your eye if you feel pain.
• D. You should resume wearing your regular glasses immediately.

Correct answer: A

Rationale: The correct answer is A: 'You should wear a protective eye shield while sleeping.' After cataract surgery, wearing a protective eye shield while sleeping is crucial to prevent accidental injury to the eye. Choice B is incorrect because patients should indeed avoid bending over, but it is not the most important instruction among the options provided. Choice C is incorrect because applying pressure to the eye if pain is felt can be harmful and should not be advised. Choice D is incorrect because patients should not resume wearing their regular glasses immediately post cataract surgery; they should wait until their healthcare provider permits.

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