Nursing Elites

1. A nurse is caring for a client who has a pressure ulcer. Which of the following findings should the nurse report to the provider?

• A. Eschar
• B. Slough
• C. Granulation tissue
• D. Undermining

Correct answer: D

Rationale: The correct answer is D, 'Undermining.' Undermining occurs when the tissue under the wound edges erodes, indicating poor healing progress. This finding should be reported to the provider as it suggests delayed wound healing and may require intervention. Choice A, 'Eschar,' is a thick, hard, black/brown necrotic tissue that forms over a wound. While it indicates a non-healing wound, it is not as concerning as undermining. Choice B, 'Slough,' is a soft, moist, yellow/white tissue that is also a sign of necrosis. While the presence of slough indicates the need for wound cleaning and debridement, it is not as critical to report as undermining. Choice C, 'Granulation tissue,' is new tissue that forms during wound healing and is a positive sign. The presence of granulation tissue indicates that the wound is progressing through the healing stages and is not a finding that requires immediate reporting to the provider.

2. Which lab value is essential for a patient receiving warfarin therapy?

• A. Monitor INR
• B. Monitor sodium levels
• C. Monitor potassium levels
• D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor the INR (International Normalized Ratio) for a patient receiving warfarin therapy. INR monitoring is crucial to assess the effectiveness of warfarin in preventing blood clots while minimizing the risk of bleeding. Monitoring sodium levels (choice B), potassium levels (choice C), or platelet count (choice D) is not specifically essential for patients on warfarin therapy and does not provide direct information on the drug's anticoagulant effects.

3. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?

• A. Increased urine output.
• B. Hyperactive reflexes.
• C. Hypoactive bowel sounds.
• D. Facial weakness.

Correct answer: D

Rationale: Facial weakness is a common finding in clients with Guillain-Barré syndrome due to muscle weakness. While increased urine output is not typically associated with Guillain-Barré syndrome, hyperactive reflexes are more indicative of conditions like hyperthyroidism or spinal cord injury. Hypoactive bowel sounds are not a classic finding in Guillain-Barré syndrome, making it an incorrect choice.

4. A client is postoperative following a hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to lie flat in bed.
• B. Apply heat to the incision site.
• C. Use an abduction pillow between the client's legs.
• D. Place a trochanter roll under the client's knees.

Correct answer: C

Rationale: Using an abduction pillow between the client's legs is essential in maintaining proper alignment and preventing dislocation of the hip joint following a hip arthroplasty. Encouraging the client to lie flat in bed (Choice A) is not recommended as early mobilization is crucial for preventing complications. Applying heat to the incision site (Choice B) is not typically done immediately postoperatively. Placing a trochanter roll under the client's knees (Choice D) is not as beneficial as using an abduction pillow to maintain proper positioning.

5. A nurse is caring for a client who is 12 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Respiratory rate of 16/min.
• C. Heart rate of 90/min.
• D. WBC count of 15,000/mm3.

Correct answer: D

Rationale: A WBC count of 15,000/mm3 is elevated, which may indicate infection, a common concern postoperatively. An elevated WBC count suggests the body is fighting an infection, and prompt reporting to the provider is essential for further evaluation and treatment. Serosanguineous drainage on the surgical dressing is expected in the immediate postoperative period, respiratory rate of 16/min is within the normal range, and a heart rate of 90/min is also within an acceptable range postoperatively. Therefore, these findings do not raise immediate concerns that necessitate reporting to the provider.

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