Nursing Elites

1. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5.5 hours. How much heparin has the client received?

• A. 11,000 units.
• B. 13,000 units.
• C. 15,000 units.
• D. 17,000 units.

Correct answer: A

Rationale: To calculate the total amount of heparin received, multiply the infusion rate (50 ml/hour) by the total infusion time (5.5 hours). This results in 275 ml of the solution infused. Since there are 20,000 units of heparin in 500 ml, there are 800 units per ml. Therefore, 275 ml contains 220,000 units. However, the heparin is diluted in 500 ml, so the client has received half of this amount, which is 110,000 units. Therefore, the correct answer is 11,000 units. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

2. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

• A. 16-year-old who had an open reduction of a fractured wrist 10 hours ago
• B. 20-year-old in skeletal traction for 2 weeks since a motorcycle accident
• C. 72-year-old recovering from surgery after a hip replacement 2 hours ago
• D. 75-year-old who is in skin traction prior to planned hip pinning surgery

Correct answer: C

Rationale: The 72-year-old recovering from surgery after a hip replacement 2 hours ago should be seen first due to the potential for immediate post-operative complications. This patient is in the immediate postoperative period and requires close monitoring for any signs of complications such as bleeding, infection, or impaired circulation. The other patients are relatively stable compared to the patient who just had surgery and therefore can wait for assessment and care without immediate risk. The 16-year-old had surgery ten hours ago, which is longer than the 72-year-old and is at a lower risk for immediate complications. The 20-year-old in skeletal traction for two weeks is stable in his current condition. The 75-year-old in skin traction before planned surgery does not require immediate attention as the surgery has not yet taken place.

3. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

• A. Perform deep palpation at the end of the admission assessment
• B. Auscultate the client’s abdomen before palpation
• C. Begin palpation of the abdomen at the site of pain
• D. Assess the client’s bowel sounds using the bell of the stethoscope

Correct answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

4. A client who is postoperative is using an incentive spirometer. Into which of the following positions should the nurse place the client?

• A. Side-lying
• B. Supine
• C. Semi-Fowler’s
• D. Trendelenburg

Correct answer: C

Rationale: The correct position for a postoperative client using an incentive spirometer is the Semi-Fowler’s position. Placing the client in Semi-Fowler’s or high-Fowler’s position maximizes lung expansion and the effectiveness of the incentive spirometer. Side-lying may not provide optimal lung expansion. The supine position is not ideal for postoperative clients using incentive spirometers as it may limit lung expansion. The Trendelenburg position is not recommended due to potential complications postoperatively.

5. A postoperative client is reporting pain at a level of 2 on a scale of 0 to 10. What is an indication that the client understands pain management?

• A. It might help me to listen to music while lying in bed.
• B. I should try to sleep as much as possible to avoid pain.
• C. I don’t need pain medication if my pain is only at a 2.
• D. I will try to use the pain management techniques suggested by the nurse.

Correct answer: A

Rationale: The correct answer is A because understanding pain management involves considering non-pharmacological approaches, such as listening to music for relaxation and comfort. Choice B is incorrect as excessive sleep may not be an effective pain management strategy. Choice C is incorrect because pain medication may still be necessary even if pain levels are low. Choice D is not the best answer, as it simply states following the nurse’s suggestions without demonstrating an understanding of personalized pain management techniques.

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