Nursing Elites

1. A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Blood pressure 110/70 mm Hg
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: A low urine output of 20 mL/hr, less than the expected 30 mL/hr or more, could indicate renal impairment or inadequate fluid status postoperatively. In this scenario, early detection and intervention are crucial to prevent further complications. The other findings - heart rate of 88/min, pain rating of 4, and blood pressure of 110/70 mm Hg - are within normal limits for a client 2 hr postoperative following an inguinal hernia repair and do not raise immediate concerns.

2. A client with rheumatoid arthritis is experiencing morning stiffness. Which of the following actions should the nurse take?

• A. Encourage the client to avoid physical activity in the morning.
• B. Encourage the client to take NSAIDs before bedtime.
• C. Apply cold packs to the affected joints in the morning.
• D. Perform passive range-of-motion exercises before getting out of bed.

Correct answer: C

Rationale: The correct action the nurse should take is to apply cold packs to the affected joints in the morning. Rheumatoid arthritis is characterized by inflammation, and applying cold packs can help reduce inflammation and stiffness in the joints. Encouraging the client to avoid physical activity in the morning (Choice A) may worsen stiffness, as movement is beneficial for joint mobility. While NSAIDs (Choice B) can help with pain and inflammation, applying cold packs directly to the affected joints is more targeted and effective. Performing passive range-of-motion exercises (Choice D) can be helpful, but applying cold packs is the priority for reducing inflammation and stiffness.

3. A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Diaphoresis.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.

4. A nurse is reviewing the medical record of a client who has acute kidney injury. Which of the following findings should the nurse report to the provider?

• A. Blood urea nitrogen (BUN) 15 mg/dL
• B. Urine output of 45 mL/hr
• C. Serum creatinine 3.5 mg/dL
• D. Calcium 9 mg/dL

Correct answer: C

Rationale: The correct answer is C, 'Serum creatinine 3.5 mg/dL.' An elevated serum creatinine level indicates worsening kidney function and impaired renal clearance, which should be reported to the provider promptly. Choice A, 'Blood urea nitrogen (BUN) 15 mg/dL,' is within the normal range (7-20 mg/dL) and does not indicate acute kidney injury. Choice B, 'Urine output of 45 mL/hr,' is a low urine output but does not directly reflect kidney function decline. Choice D, 'Calcium 9 mg/dL,' is within the normal calcium range (8.5-10.5 mg/dL) and is not specifically indicative of acute kidney injury.

5. A nurse is assessing a client who has a history of gastroesophageal reflux disease (GERD). Which of the following findings should the nurse identify as a complication of GERD?

• A. Hematemesis.
• B. Melena.
• C. Pallor.
• D. Steatorrhea.

Correct answer: A

Rationale: The correct answer is A: Hematemesis. Hematemesis (vomiting blood) is a sign of gastrointestinal bleeding and a serious complication of GERD. Melena (black, tarry stool) is also a sign of GI bleeding but is not as specific to GERD as hematemesis. Pallor may be present due to anemia from chronic blood loss, but it is not a direct complication of GERD. Steatorrhea is not typically associated with GERD; it is more indicative of malabsorption issues.

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