Nursing Elites

1. A client is postoperative following cataract surgery. Which of the following instructions should the nurse include?

• A. Avoid lying flat for 24 hours after surgery.
• B. Avoid bending at the waist.
• C. Wear an eye patch at night for 1 week.
• D. Sleep on your affected side to reduce discomfort.

Correct answer: B

Rationale: The correct instruction that the nurse should include for a client postoperative following cataract surgery is to avoid bending at the waist. Bending at the waist can increase intraocular pressure, which is not recommended after cataract surgery. Choices A, C, and D are incorrect because lying flat for 24 hours after surgery may not be necessary, wearing an eye patch at night for a week is not a standard postoperative instruction for cataract surgery, and sleeping on the affected side may not necessarily reduce discomfort and can increase pressure on the eye.

2. A client is receiving furosemide for heart failure. Which of the following findings should the nurse report to the provider?

• A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
• B. Heart rate of 68/min.
• C. Potassium level of 3.8 mEq/L.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. A heart rate of 68/min is lower than expected and should be reported as it may indicate digoxin toxicity. Choices A, C, and D are within normal limits for a client receiving furosemide for heart failure and do not require immediate reporting. Weight loss may be expected due to diuretic therapy, a potassium level of 3.8 mEq/L is within the normal range, and a urine output of 60 mL/hr indicates adequate renal perfusion.

3. A healthcare professional is reviewing a client's laboratory results. Which of the following values is a contraindication to the administration of heparin?

• A. Hemoglobin 13 g/dL
• B. Platelet count 50,000/mm³
• C. White blood cell count 6,000/mm³
• D. INR 2.5

Correct answer: B

Rationale: The correct answer is B: Platelet count 50,000/mm³. A platelet count of 50,000/mm³ increases the risk of bleeding, making heparin contraindicated. Platelets are essential for blood clotting, and a low count can lead to excessive bleeding. Choices A, C, and D are not contraindications to heparin administration. Hemoglobin level of 13 g/dL is within the normal range, white blood cell count of 6,000/mm³ is also normal, and an INR of 2.5 is within the therapeutic range for patients receiving heparin therapy.

4. What is the most important assessment for a patient post-op to monitor for complications?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood glucose levels
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: The correct answer is to monitor vital signs. Post-operative patients need close monitoring of their vital signs to detect early signs of complications such as changes in blood pressure, heart rate, temperature, and respiratory rate. While monitoring the surgical site is also important for signs of infection, assessing vital signs takes precedence as it provides immediate information about the patient's overall condition. Checking blood glucose levels may be essential for specific patients but is not the primary assessment for monitoring post-op complications. Checking for abnormal breath sounds is important but falls secondary to monitoring vital signs as it indicates respiratory issues rather than providing a comprehensive assessment of the patient's condition.

5. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?

• A. Increased urine output.
• B. Hyperactive reflexes.
• C. Hypoactive bowel sounds.
• D. Facial weakness.

Correct answer: D

Rationale: Facial weakness is a common finding in clients with Guillain-Barré syndrome due to muscle weakness. While increased urine output is not typically associated with Guillain-Barré syndrome, hyperactive reflexes are more indicative of conditions like hyperthyroidism or spinal cord injury. Hypoactive bowel sounds are not a classic finding in Guillain-Barré syndrome, making it an incorrect choice.

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