Nursing Elites

1. What is the most important nursing action for a patient post-surgery?

• A. Monitor vital signs
• B. Monitor the surgical site
• C. Check blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: The most crucial nursing action for a patient post-surgery is to monitor vital signs. Monitoring vital signs helps in detecting early signs of complications such as hemorrhage, shock, or infection. While monitoring the surgical site is important for assessing wound healing and signs of infection, it is secondary to monitoring vital signs. Checking blood pressure and oxygen saturation are also important, but they are components of monitoring vital signs.

2. A nurse is providing teaching to a client with asthma. Which of the following client statements indicates a need for further teaching?

• A. I should use my albuterol inhaler before I exercise.
• B. I should avoid using my inhaler more than twice a week.
• C. I should take my inhaler only when I feel short of breath.
• D. I should rinse my mouth after using my corticosteroid inhaler.

Correct answer: C

Rationale: The correct answer is C because the client stating they should only take the inhaler when feeling short of breath indicates a need for further teaching. Clients with asthma should use their inhaler as prescribed, not just when short of breath. Choices A, B, and D demonstrate good asthma management practices. Choice A indicates understanding of using the albuterol inhaler before exercise to prevent exercise-induced symptoms. Choice B mentions the importance of not overusing the inhaler, which can indicate poor asthma control. Choice D shows awareness of rinsing the mouth after using a corticosteroid inhaler to prevent oral thrush.

3. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel. Which of the following statements should the nurse make?

• A. The nurse is legally responsible for the actions of the AP.
• B. An AP can perform tasks outside of their scope if they have been trained.
• C. An experienced AP can delegate tasks to another AP.
• D. An RN evaluates the client's needs to determine tasks to delegate.

Correct answer: D

Rationale: The correct statement is D: 'An RN evaluates the client's needs to determine which tasks are appropriate to delegate to assistive personnel.' This is an essential step in the delegation process to ensure that tasks are assigned appropriately based on the client's condition and the competencies of the assistive personnel. Option A is incorrect because while the nurse retains accountability for delegation decisions, the AP is responsible for their actions. Option B is incorrect as tasks should be within the AP's scope of practice regardless of training. Option C is incorrect as delegation typically involves assigning tasks from the RN to the AP, not between APs.

4. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Hyperkalemia
• B. Hyperglycemia
• C. Hypokalemia
• D. Hyponatremia

Correct answer: C

Rationale: The correct answer is C: 'Hypokalemia.' Furosemide is a loop diuretic that can lead to potassium depletion (hypokalemia) due to increased urinary excretion of potassium. This can result in adverse effects such as muscle weakness, cardiac dysrhythmias, and other complications. Hyperkalemia (choice A) is not an adverse effect of furosemide but rather an elevated potassium level. Hyperglycemia (choice B) and hyponatremia (choice D) are not typically associated with furosemide use. Therefore, monitoring potassium levels and addressing hypokalemia is crucial in clients taking furosemide.

5. A nurse is assessing a client who is postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Capillary refill of 2 seconds
• C. Wound drainage of 30 mL in 8 hours
• D. Warmth and redness in the calf

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

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