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. When providing discharge instructions for a patient with diabetes, what is the most important information to include?

• A. Encourage the patient to maintain a high-carbohydrate diet.
• B. Teach the patient how to monitor their blood sugar levels.
• C. Recommend the patient engage in regular exercise.
• D. Provide the patient with a list of restricted foods.

Correct answer: B

Rationale: The most critical information to include when providing discharge instructions for a patient with diabetes is teaching them how to monitor their blood sugar levels. This empowers the patient to actively manage their condition, make informed decisions about their diet and medication, and prevent complications. Encouraging a high-carbohydrate diet (Choice A) can be detrimental for diabetic patients as it may lead to unstable blood sugar levels. While regular exercise (Choice C) is important in diabetes management, monitoring blood sugar levels takes precedence. Providing a list of restricted foods (Choice D) is relevant but not as crucial as teaching the patient how to monitor their blood sugar levels.

3. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?

• A. Hypertension, bradycardia, and oliguria
• B. Bradycardia, hypertension, and peripheral edema
• C. Tachypnea, cool skin, and confusion
• D. Tachycardia, hypotension, and decreased urine output

Correct answer: D

Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.

4. A nurse is providing discharge teaching to a client following a myocardial infarction (MI). Which of the following activities should the client avoid?

• A. Swimming in a pool
• B. Driving a car
• C. Light housework
• D. Walking on flat ground

Correct answer: B

Rationale: The correct answer is B: Driving a car. Driving a car can be physically and emotionally taxing, increasing the risk of complications soon after a myocardial infarction. It requires quick reflexes and decision-making abilities, which may be impaired during the recovery period. Swimming in a pool, light housework, and walking on flat ground are generally safe and beneficial activities for clients following a myocardial infarction as they promote circulation, muscle strength, and overall well-being.

5. What is the most important action for the nurse to take before administering digoxin to a patient?

• A. Check the patient's heart rate before administration.
• B. Assess the patient's blood pressure before administration.
• C. Ensure the patient has eaten before administration.
• D. Monitor the patient's weight before administration.

Correct answer: A

Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.

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