Nursing Elites

1. A nurse is caring for a client who is receiving chemotherapy. Which of the following findings should the nurse report to the provider?

• A. Alopecia
• B. Weight gain of 1 kg (2.2 lb) in 24 hours
• C. White blood cell count of 6,000/mm³
• D. Temperature of 37.2°C (99°F)

Correct answer: B

Rationale: The correct answer is B. A weight gain of 1 kg (2.2 lb) in 24 hours is concerning as it indicates fluid retention, which can be a sign of complications in clients receiving chemotherapy. Rapid weight gain can be associated with conditions like fluid overload or electrolyte imbalances, which need prompt medical attention. Choices A, C, and D are not typically immediate concerns related to chemotherapy. Alopecia (choice A) is a common side effect of chemotherapy, a white blood cell count of 6,000/mm³ (choice C) falls within the normal range, and a temperature of 37.2°C (99°F) (choice D) is slightly elevated but not a critical finding in this context.

2. What lab value should a healthcare provider monitor for a patient on warfarin therapy?

• A. Potassium
• B. PT/INR
• C. Sodium
• D. Calcium

Correct answer: B

Rationale: The correct answer is B: PT/INR. When a patient is on warfarin therapy, healthcare providers monitor the PT/INR levels to evaluate the effectiveness of the treatment and assess the risk of bleeding. Monitoring potassium, sodium, or calcium levels is not directly related to warfarin therapy and would not provide the necessary information needed to manage the medication effectively.

3. A client is postoperative following a total knee arthroplasty. Which of the following instructions should the nurse include in the discharge teaching?

• A. Cross your legs when sitting to prevent discomfort.
• B. Perform range-of-motion exercises every 4 hours.
• C. Wear compression stockings daily.
• D. Apply heat to the incision site daily.

Correct answer: C

Rationale: The correct answer is C: 'Wear compression stockings daily.' Wearing compression stockings is essential after knee surgery to prevent venous stasis and reduce the risk of blood clots. Choice A is incorrect as crossing legs when sitting can increase the risk of blood clots. Choice B is incorrect because performing range-of-motion exercises every 4 hours may not be suitable for all clients post total knee arthroplasty. Choice D is incorrect as applying heat to the incision site can increase the risk of infection.

4. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?

• A. Your baby needs an IV because she is not producing any tears
• B. Your baby needs an IV because her fontanels are bulging
• C. Your baby needs an IV because she is breathing slower than normal
• D. Your baby needs an IV because her heart rate is decreasing

Correct answer: A

Rationale: The correct answer is A. A lack of tear production is a sign of severe dehydration in infants, indicating the need for IV therapy. Option B, bulging fontanels, is a sign of increased intracranial pressure, not dehydration. Option C, breathing slower than normal, and Option D, decreasing heart rate, are not specific signs of severe dehydration that would indicate the need for IV therapy in this case.

5. A nurse is assessing a client who has a new diagnosis of diabetes mellitus. Which of the following findings should the nurse expect?

• A. Increased urinary output.
• B. Weight gain.
• C. Blurred vision.
• D. Diaphoresis.

Correct answer: A

Rationale: Increased urinary output is a common finding in clients with diabetes mellitus due to hyperglycemia and osmotic diuresis. This results in the body trying to eliminate excess glucose through urine, leading to increased urinary frequency and volume. Weight gain is not typically associated with diabetes mellitus but may occur in poorly controlled cases due to increased calorie intake. Blurred vision is more commonly associated with acute complications like hyperglycemia or hypoglycemia. Diaphoresis, or excessive sweating, is not a typical finding in diabetes mellitus but can be seen in conditions like hypoglycemia.

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