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. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?

• A. Low back pain
• B. Dyspnea
• C. Hypotension
• D. Thready pulse

Correct answer: B

Rationale: The correct answer is B: Dyspnea. Dyspnea, or difficulty breathing, is a common sign of fluid overload in a client receiving packed RBCs. When fluid accumulates in the lungs due to overload, it can lead to respiratory distress. This finding requires prompt intervention to prevent further complications. Choices A, C, and D are incorrect: A) Low back pain is not typically associated with fluid overload; C) Hypotension refers to low blood pressure and is not a typical finding in fluid overload; D) Thready pulse may indicate poor perfusion but is not a direct indicator of fluid overload.

3. While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?

• A. Ensure the eye shield is covering the eyes.
• B. Apply lotion to the exposed skin.
• C. Offer glucose water between feedings.
• D. Discontinue breastfeeding during treatment.

Correct answer: A

Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.

4. A nurse is preparing to administer potassium chloride IV to a client who has hypokalemia. Which of the following actions should the nurse take?

• A. Give the medication as a bolus over 10 minutes.
• B. Dilute the medication before administration.
• C. Infuse the medication at a rate of 10 mEq/hr.
• D. Administer the medication undiluted.

Correct answer: C

Rationale: The correct action the nurse should take when administering potassium chloride IV to a client with hypokalemia is to infuse the medication at a rate of 10 mEq/hr. This slow infusion rate is crucial to prevent the development of hyperkalemia, a potentially dangerous condition. Option A is incorrect because giving the medication as a bolus over 10 minutes can lead to adverse effects. Option B is incorrect as potassium chloride does not necessarily need to be diluted before administration in this scenario. Option D is incorrect as administering the medication undiluted can also increase the risk of hyperkalemia.

5. A healthcare provider is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome (IBS). Which of the following foods should the healthcare provider instruct the client to avoid?

• A. Lean cuts of pork.
• B. Low-fat yogurt.
• C. White bread.
• D. Oatmeal.

Correct answer: D

Rationale: The correct answer is D, oatmeal. Oatmeal contains insoluble fiber, which can exacerbate the symptoms of irritable bowel syndrome. Choices A, B, and C are not typically problematic for individuals with IBS. Lean cuts of pork, low-fat yogurt, and white bread are generally well-tolerated and may even be recommended as part of a balanced diet for individuals with IBS.

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