Nursing Elites

1. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Heart rate of 88/min.
• C. Blood pressure of 118/76 mm Hg.
• D. Temperature of 38.8°C (101.8°F).

Correct answer: D

Rationale: A temperature of 38.8°C (101.8°F) is above the normal range and may indicate infection, which should be reported. Elevated temperature postoperatively can be a sign of infection, especially in the early postoperative period. Serosanguineous drainage on the surgical dressing is expected in the early postoperative period. A heart rate of 88/min and a blood pressure of 118/76 mm Hg are within normal ranges and do not necessarily indicate a complication postoperatively.

2. A nurse is assessing a client who has a chest tube and notes continuous bubbling in the water seal chamber. Which of the following actions should the nurse take?

• A. Continue to monitor the client.
• B. Clamp the chest tube.
• C. Replace the drainage system.
• D. Apply a dressing over the insertion site.

Correct answer: D

Rationale: The correct action for the nurse to take when continuous bubbling is noted in the water seal chamber of a chest tube is to apply a dressing over the insertion site. Continuous bubbling indicates an air leak, and applying a dressing helps manage this issue by providing a seal. Clamping the chest tube or replacing the drainage system is not appropriate in this situation as it can lead to complications such as tension pneumothorax or inadequate drainage of the pleural space.

3. A nurse is reviewing the laboratory results of a client who is receiving warfarin therapy for atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

• A. INR 1.8
• B. Hemoglobin 14 g/dL
• C. Platelets 175,000/mm³
• D. Potassium 3.8 mEq/L

Correct answer: A

Rationale: The correct answer is A. An INR of 1.8 is below the therapeutic range for a client receiving warfarin, indicating a potential risk of blood clots. This value should be reported to the provider for further evaluation and possible adjustment of the warfarin dosage. Choices B, C, and D are within normal ranges and do not directly relate to the effectiveness or safety of warfarin therapy in this scenario, making them less urgent to report.

4. A nurse is assessing a school-age child with a urinary tract infection. Which symptom should the nurse expect?

• A. Periorbital edema.
• B. Decreased frequency of urination.
• C. Enuresis.
• D. Diarrhea.

Correct answer: C

Rationale: Enuresis is a common symptom of urinary tract infections in school-age children. It is often a presenting symptom due to irritation of the bladder. Periorbital edema (Choice A) is more indicative of conditions like nephrotic syndrome or renal disorders. Decreased frequency of urination (Choice B) is not typically associated with urinary tract infections. Diarrhea (Choice D) is not a common symptom of urinary tract infections but may occur due to other reasons like gastrointestinal infections.

5. A nurse is caring for a client who is receiving radiation therapy. Which of the following findings should the nurse expect?

• A. Weight gain
• B. Mouth sores
• C. Hyperpigmentation
• D. Increased saliva production

Correct answer: B

Rationale: The correct answer is B: Mouth sores. Mouth sores are a common side effect of radiation therapy, especially when the treatment is focused on the head or neck area. Weight gain is not typically associated with radiation therapy; instead, clients may experience weight loss due to side effects like nausea and loss of appetite. Hyperpigmentation is not a common finding related to radiation therapy. Increased saliva production is not a typical side effect of radiation therapy; instead, clients may experience dry mouth.

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