Nursing Elites

1. The nurse is assessing a first-day postpartum client. Which finding is most indicative of a postpartum infection?

• A. Oral temperature of 100.2°F (37.9°C)
• B. Blood pressure of 122/74 mmHg
• C. Moderate amount of foul-smelling lochia
• D. White blood count of 19,000/mm³ (19x10^9/L SI units)

Correct answer: C

Rationale: A foul-smelling lochia is indicative of a postpartum infection, such as endometritis. Foul-smelling lochia suggests the presence of infection due to the breakdown of tissue by bacteria, leading to the malodor. An oral temperature elevation and an elevated white blood cell count are nonspecific and can be present in various conditions other than postpartum infections, making them less indicative. A blood pressure within normal limits is not typically associated with postpartum infections.

2. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client’s statements?

• A. Remind the client that it is also important to schedule an annual mammogram.
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure.
• C. Encourage the client to perform BSE 2 to 3 days after her menstrual period ends.
• D. Instruct the client to continue with her regular monthly exams as she is doing.

Correct answer: C

Rationale: The correct answer is to encourage the client to perform BSE 2 to 3 days after her menstrual period ends. This timing is recommended because breasts are least tender and swollen at this point, making it easier to detect any abnormalities. Choice A is incorrect because while scheduling an annual mammogram is important, it is not the immediate action needed based on the client's statements. Choice B is incorrect as the client's BSE technique timing needs adjustment rather than an in-depth review by a nurse practitioner. Choice D is incorrect because the client should modify the timing of the BSE for better effectiveness.

3. A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first?

• A. Determine serum potassium level
• B. Calculate the client’s daily fluid intake
• C. Assess client for signs of vertigo
• D. Review the client’s pulse oximetry reading

Correct answer: A

Rationale: The correct answer is to determine the client's serum potassium level. In a client with renal disease experiencing symptoms like shortness of breath, lethargy, edema, and weight gain, assessing serum potassium levels is crucial. Electrolyte imbalances, including potassium, can lead to serious complications such as cardiac arrhythmias and muscle weakness. Calculating daily fluid intake may be important but addressing acute symptoms related to electrolyte imbalances takes precedence. Assessing for signs of vertigo and reviewing pulse oximetry reading are not the priority in this scenario compared to assessing and managing potential electrolyte imbalances.

4. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Monitor urine output hourly
• B. Assess for back muscle aches
• C. Record drainage from the drain
• D. Obtain body weight daily

Correct answer: C

Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.

5. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?

• A. Decreased white blood cell count
• B. Pruritus and muscle aches
• C. Elevated liver function tests
• D. Vomiting and diarrhea

Correct answer: C

Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.

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