Nursing Elites

1. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?

• A. Mild redness at the incision site.
• B. Increased drainage from the surgical site.
• C. Fever of 101°F.
• D. Normal white blood cell count.

Correct answer: C

Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.

2. A client with HIV-1 starting therapy with ritonavir and zidovudine asks why both medications are necessary. What explanation should the nurse provide?

• A. Taking two medications ensures a faster recovery.
• B. The medications work best together to improve your immune system.
• C. Taking the 2 medications together keeps you from becoming resistant to either of them.
• D. These medications target different parts of the virus.

Correct answer: C

Rationale: The correct answer is C because taking two medications together helps prevent the development of drug resistance in HIV treatment. Choice A is incorrect because the primary goal of combination therapy is not necessarily a faster recovery. Choice B is incorrect as the main purpose of combining medications in HIV treatment is to prevent resistance rather than improving the immune system. Choice D is incorrect because while it is true that the medications may target different parts of the virus, the main reason for using both together is to prevent resistance.

3. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?

• A. Restrict the patient's fluid intake.
• B. Monitor the patient's daily weight.
• C. Administer diuretics as prescribed.
• D. Increase the patient's salt intake to promote fluid balance.

Correct answer: B

Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.

4. A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?

• A. Notify the provider
• B. Check the condition of the client
• C. Document the occurrence in the electronic medical record
• D. Complete an incident report

Correct answer: B

Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.

5. How is the effectiveness of a diuretic in a patient with heart failure evaluated?

• A. Checking daily weights and lung sounds for improvement
• B. Assessing the patient's blood pressure and urine output
• C. Monitoring for weight loss and reduction in edema
• D. Measuring the patient's heart rate and lung sounds

Correct answer: A

Rationale: The correct way to evaluate the effectiveness of a diuretic in a patient with heart failure is by checking daily weights and lung sounds for improvement. Daily weights help to assess fluid retention changes, while improvement in lung sounds indicates reduced pulmonary congestion. Assessing blood pressure and urine output (Choice B) is important but does not directly evaluate the effectiveness of the diuretic. Monitoring for weight loss and reduction in edema (Choice C) are valid indicators of diuretic effectiveness, but direct observation of daily weights and lung sounds is more specific. Measuring heart rate and lung sounds (Choice D) is relevant but does not directly assess the impact of the diuretic on fluid balance and pulmonary status.

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