Nursing Elites

1. A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?

• A. Stoma that is red and moist
• B. Purulent drainage from the stoma
• C. Stoma that is dry and purple
• D. Mild swelling around the stoma

Correct answer: C

Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.

2. A nurse is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Client reports taking warfarin
• B. Client has a history of hypertension
• C. Client ate a light breakfast 2 hours prior
• D. Client reports a history of smoking 10 cigarettes a day

Correct answer: A

Rationale: The correct answer is A. Warfarin is an anticoagulant that increases the risk of bleeding during surgery. It is crucial for the provider to be informed about the client taking warfarin to adjust the treatment plan accordingly. Choices B, C, and D are not as critical to report for surgical planning. A history of hypertension (B) is important but may not require immediate intervention for surgery. Eating a light breakfast 2 hours prior (C) is a normal preoperative instruction. Smoking history (D) is relevant for overall health assessment but is not as urgent as the use of warfarin before surgery.

3. What is the best intervention for a patient with constipation?

• A. Administer a stool softener
• B. Encourage fluid intake
• C. Provide a high-fiber diet
• D. Administer a laxative

Correct answer: B

Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.

4. A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

• A. Barrel-shaped chest
• B. Bradycardia
• C. Increased respiratory rate
• D. Tracheal deviation

Correct answer: C

Rationale: Corrected Rationale: An increased respiratory rate is a common finding in clients with ARDS as the body attempts to compensate for impaired gas exchange. Barrel-shaped chest (Choice A) is associated with conditions like COPD, not ARDS. Bradycardia (Choice B) is unlikely in ARDS due to the body's compensatory mechanisms to improve oxygenation. Tracheal deviation (Choice D) is not typically seen in ARDS and is more suggestive of other respiratory conditions.

5. A nurse is assessing a newborn who is 12 hours old. Which of the following findings should the nurse report to the provider?

• A. Heart rate 140/min.
• B. A bulging anterior fontanel.
• C. Respiratory rate 50/min.
• D. Blood glucose 45 mg/dL.

Correct answer: D

Rationale: A blood glucose level of 45 mg/dL is below the normal range for a newborn and indicates hypoglycemia, which can lead to serious complications if left untreated. Therefore, this finding should be reported to the provider immediately. Choices A, B, and C are within normal ranges for a newborn and do not require immediate reporting. A heart rate of 140/min, a bulging anterior fontanel, and a respiratory rate of 50/min are all common findings in a newborn and do not raise immediate concerns.

Similar Questions