Nursing Elites

1. How should a healthcare professional respond to a patient who is experiencing confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Encourage deep breathing exercises
• D. Perform a neurological exam

Correct answer: A

Rationale: Administering oxygen is the most appropriate initial response to a patient experiencing confusion after surgery. Confusion can be a sign of hypoxia, which is inadequate oxygen supply to the brain. Administering oxygen helps ensure that the patient is getting enough oxygen, addressing a potential cause of the confusion. Repositioning the patient, encouraging deep breathing exercises, or performing a neurological exam may be necessary depending on the situation, but addressing potential hypoxia should be the priority in a confused post-operative patient.

2. A client is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Respiratory rate of 10/min
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. While a heart rate of 88/min, pain rating of 4, and a temperature of 37.2°C (99°F) are within normal ranges and do not indicate immediate concern related to morphine administration.

3. A nurse is caring for a client who has a pressure ulcer. Which of the following findings should the nurse report to the provider?

• A. Eschar
• B. Slough
• C. Granulation tissue
• D. Undermining

Correct answer: D

Rationale: The correct answer is D, 'Undermining.' Undermining occurs when the tissue under the wound edges erodes, indicating poor healing progress. This finding should be reported to the provider as it suggests delayed wound healing and may require intervention. Choice A, 'Eschar,' is a thick, hard, black/brown necrotic tissue that forms over a wound. While it indicates a non-healing wound, it is not as concerning as undermining. Choice B, 'Slough,' is a soft, moist, yellow/white tissue that is also a sign of necrosis. While the presence of slough indicates the need for wound cleaning and debridement, it is not as critical to report as undermining. Choice C, 'Granulation tissue,' is new tissue that forms during wound healing and is a positive sign. The presence of granulation tissue indicates that the wound is progressing through the healing stages and is not a finding that requires immediate reporting to the provider.

4. A nurse is assessing a client who has a deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

• A. Calf tenderness.
• B. Shortness of breath.
• C. Elevated blood pressure.
• D. Respiratory rate of 18/min.

Correct answer: B

Rationale: Shortness of breath is a critical finding that can indicate a pulmonary embolism, a severe complication of DVT. This symptom suggests a potential life-threatening situation and requires immediate intervention. Calf tenderness, while common in DVT, is not as urgent as shortness of breath. Elevated blood pressure and a respiratory rate of 18/min are important to assess but are not typically as indicative of a serious complication like a pulmonary embolism.

5. A client with a new diagnosis of hypertension is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will check my blood pressure at least once a week.
• B. I will avoid eating foods high in potassium.
• C. I should exercise for 30 minutes at least 5 days a week.
• D. I will take my medication only when I feel dizzy.

Correct answer: C

Rationale: The correct answer is C. Regular exercise is an essential component in managing hypertension. Exercising for at least 30 minutes a day, at least 5 days a week, can help control blood pressure. Checking blood pressure regularly (choice A) is important, but not as indicative of understanding the teaching as the commitment to regular exercise. Avoiding foods high in potassium (choice B) is not a typical recommendation for managing hypertension. Taking medication only when feeling dizzy (choice D) is incorrect and potentially dangerous; medications should be taken as prescribed by the healthcare provider.

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