Nursing Elites

1. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

• A. Serum potassium level of 4.2 mEq/L
• B. Blood pressure of 138/84 mm Hg
• C. Platelet count of 150,000/mm³
• D. INR of 2.0

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

2. A nurse is assessing a client who is 2 hours postoperative following a gastrectomy. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 94/min
• B. Oxygen saturation of 88%
• C. Respiratory rate of 18/min
• D. Temperature of 37.6°C (99.7°F)

Correct answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a serious condition post-gastrectomy. Hypoxemia can lead to inadequate oxygen delivery to tissues, potentially causing complications like organ dysfunction or failure. This finding requires immediate attention to prevent further deterioration. The heart rate, respiratory rate, and temperature are within normal ranges for a client post-gastrectomy, so they do not require immediate reporting to the provider.

3. A nurse is caring for a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Hypotension
• C. Dry mucous membranes
• D. Tachypnea

Correct answer: C

Rationale: Correct! Dry mucous membranes are a common finding in clients with dehydration. Dehydration leads to reduced fluid volume in the body, resulting in dryness of mucous membranes, decreased skin turgor, and thirst. Bradycardia (slow heart rate) is not typically associated with dehydration, as the body tries to compensate for decreased fluid volume by increasing heart rate. Hypotension (low blood pressure) is a possible finding in dehydration due to reduced circulating volume. Tachypnea (rapid breathing) is more commonly seen in conditions like respiratory distress or metabolic acidosis, rather than dehydration.

4. A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. What intervention should the nurse anticipate?

• A. Clamp the catheter.
• B. Administer a fluid bolus.
• C. Obtain a urine specimen for culture and sensitivity.
• D. Initiate continuous bladder irrigation.

Correct answer: D

Rationale: In this scenario, the nurse should anticipate initiating continuous bladder irrigation. Dark yellow urine output at a rate of 25 ml/hr following abdominal surgery may indicate urinary stasis or obstruction, which could lead to complications like urinary retention. Continuous bladder irrigation helps prevent catheter obstruction and manage urinary retention by ensuring patency and promoting urine flow. Clamping the catheter (Choice A) could lead to urinary stasis and should be avoided. Administering a fluid bolus (Choice B) is not indicated solely based on the urine color and output described. Obtaining a urine specimen for culture and sensitivity (Choice C) may be necessary for assessing infection but does not directly address the issue of urinary stasis or obstruction.

5. Which lab value should be closely monitored for a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor potassium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.

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