Nursing Elites

1. A nurse is caring for a client who is 2 hours postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

• A. Urine output of 20 mL/hr.
• B. Temperature of 36.5°C (97.7°F).
• C. Sanguineous drainage on the surgical dressing.
• D. WBC count of 9,000/mm3.

Correct answer: A

Rationale: The correct answer is A: Urine output of 20 mL/hr. A urine output less than 30 mL/hr can indicate decreased renal perfusion, potentially due to hypovolemia or other issues, and should be reported to the provider. B: A temperature of 36.5°C (97.7°F) falls within the normal range and does not require immediate reporting. C: Sanguineous drainage on the surgical dressing is expected in the early postoperative period and should be monitored but does not need immediate reporting unless excessive. D: A WBC count of 9,000/mm3 is within the normal range and does not indicate an immediate concern.

2. A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?

• A. Low birth weight
• B. Advanced maternal age
• C. Single parenthood
• D. Premature birth

Correct answer: A

Rationale: Low birth weight increases a child's vulnerability to physical maltreatment due to additional care needs. Advanced maternal age (choice B) is not directly linked to an increased risk of physical maltreatment. Single parenthood (choice C) is not a characteristic that inherently increases the risk of physical maltreatment. Premature birth (choice D) is not listed as a characteristic that directly increases a child's risk of physical maltreatment.

3. A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

• A. Tomatoes
• B. Carrots
• C. Avocados
• D. Apricots

Correct answer: A

Rationale: Tomatoes are high in vitamin C, which is crucial for wound healing, making them an excellent recommendation for a client with a burn injury. Carrots, avocados, and apricots are not as rich in vitamin C compared to tomatoes, and therefore, they are not the best choice for promoting healing in this scenario.

4. What is the best teaching point for a client with left-leg weakness learning to use a cane?

• A. Use the cane on the weaker side
• B. Maintain two points of support on the floor at all times
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg together

Correct answer: B

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures better stability and support for the client while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice C is incorrect as advancing the cane too far with each step may compromise balance. Choice D is incorrect because advancing the cane and the strong leg together may not provide adequate support for the weaker leg.

5. A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?

• A. Drooping eyelids
• B. Unequal pupils
• C. Facial twitching
• D. Facial droop

Correct answer: A

Rationale: The correct answer is A: 'Drooping eyelids.' Ptosis, characterized by drooping of the eyelid, is a classic symptom seen in myasthenia gravis. This occurs due to muscle weakness, particularly in the muscles that control eyelid movement. Choice B, 'Unequal pupils,' is not associated with ptosis and may indicate other neurological issues. Choice C, 'Facial twitching,' is not a typical sign of ptosis but could be related to other conditions like nerve irritation. Choice D, 'Facial droop,' is more commonly seen in conditions affecting the facial nerve, like Bell's palsy, and is not a characteristic feature of myasthenia gravis.

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