Nursing Elites

1. A nurse is caring for a client who is 1 day postoperative following an open reduction and internal fixation of the right tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 88/min
• D. Pallor of the affected extremity

Correct answer: D

Rationale: Pallor of the affected extremity could indicate impaired circulation, such as compromised blood flow to the area, which is crucial to monitor postoperatively. This finding suggests potential vascular compromise or decreased blood supply to the extremity, which is a serious concern and should be reported promptly to the provider for further evaluation and intervention. Serous drainage on the dressing is a normal finding in the immediate postoperative period and does not necessarily indicate a complication requiring immediate provider notification. Capillary refill of 2 seconds is within the normal range (less than 3 seconds) and indicates adequate peripheral perfusion. A heart rate of 88/min is also within the normal range for an adult and is not typically a cause for immediate concern postoperatively.

2. Which electrolyte imbalance is commonly seen in patients receiving furosemide?

• A. Hypokalemia
• B. Hypercalcemia
• C. Hyponatremia
• D. Hyperkalemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance necessitates close monitoring to prevent complications such as cardiac arrhythmias. Choices B, C, and D are incorrect. Hypercalcemia is not a common side effect of furosemide. Hyponatremia is more commonly associated with other medications like thiazide diuretics. Hyperkalemia is the opposite electrolyte imbalance and is not typically seen with furosemide use.

3. How should bleeding in a patient on warfarin be monitored?

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

Correct answer: A

Rationale: The correct answer is to monitor INR levels. INR levels are the most critical indicator for monitoring bleeding risk in patients on warfarin. INR stands for International Normalized Ratio and specifically measures the clotting tendency of the blood. Monitoring hemoglobin levels, potassium levels, or platelet count are not as directly relevant to assessing bleeding risk in patients on warfarin.

4. A client with a new prescription for levothyroxine is receiving discharge teaching. Which of the following client statements indicates an understanding of the teaching?

• A. I should take this medication with food to prevent nausea.
• B. I will take this medication every morning before breakfast.
• C. I will stop taking this medication if I experience chest pain.
• D. I will take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Levothyroxine should be taken every morning before breakfast to enhance absorption and maintain consistent thyroid hormone levels. Option A is incorrect because levothyroxine should be taken on an empty stomach. Option C is incorrect because chest pain is not a common side effect of levothyroxine and stopping the medication abruptly can be harmful. Option D is incorrect because taking levothyroxine at bedtime may result in decreased absorption due to interactions with food and other medications.

5. A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider recommend?

• A. Carrots
• B. Whole grains
• C. Lean beef
• D. Bananas

Correct answer: C

Rationale: The correct answer is 'Lean beef.' Lean beef is a good source of protein, which is essential for a balanced diet. While carrots and bananas are healthy food choices, they are not specifically recommended for clients with hypertension. Whole grains are a better alternative to refined grains for individuals with hypertension, but lean beef is a more suitable recommendation due to its protein content.

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