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 assessing a client who is postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Capillary refill of 2 seconds
• C. Wound drainage of 30 mL in 8 hours
• D. Warmth and redness in the calf

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

3. A client with osteoporosis should be encouraged to perform which of the following interventions as part of the plan of care?

• A. Encourage the client to increase calcium intake.
• B. Apply heat to the affected joints to reduce stiffness.
• C. Encourage weight-bearing exercises to prevent bone loss.
• D. Limit fluid intake to prevent swelling.

Correct answer: C

Rationale: The correct answer is to encourage weight-bearing exercises to prevent bone loss in clients with osteoporosis. Weight-bearing exercises help to strengthen bones and reduce the risk of fractures. Increasing calcium intake (Choice A) is important for bone health but is not the priority intervention for preventing bone loss in osteoporosis. Applying heat to affected joints (Choice B) may help with stiffness but does not address the underlying bone loss in osteoporosis. Limiting fluid intake (Choice D) is not relevant to managing osteoporosis and preventing bone loss.

4. A client is receiving radiation therapy for cancer. Which of the following skin care instructions should the nurse include in the teaching?

• A. Apply alcohol-free lotions to your skin to prevent dryness.
• B. Avoid exposing the irradiated area to direct sunlight.
• C. Cleanse the irradiated area with mild soap and water.
• D. Apply ice packs to the irradiated area to prevent swelling.

Correct answer: B

Rationale: The correct answer is to avoid exposing the irradiated area to direct sunlight. Direct sunlight can further damage the skin during radiation therapy. Choice A is incorrect because alcohol-based lotions can irritate the skin further. Choice C is incorrect because mild soap and water can be drying to the skin. Choice D is incorrect because applying ice packs can cause additional skin damage during radiation therapy.

5. A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?

• A. Potassium 4.0 mEq/L
• B. Hemoglobin 12 g/dL
• C. BUN 18 mg/dL
• D. Sodium 137 mEq/L

Correct answer: B

Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.

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