Nursing Elites

1. A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?

• A. Notify the doctor
• B. Empty the drain
• C. Do nothing
• D. Remove the drain

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.

2. The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?

• A. Assist the client to a sitting position at the edge of the bed
• B. Have the client march in place for 30 seconds
• C. Have the client raise his arms above his head
• D. Ask the client the last time he fell

Correct answer: A

Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.

3. The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best?

• A. Call the staff nurse in and place them on a work improvement plan after a 3-day suspension
• B. Have the other staff gather additional information on the tardy staff member
• C. Call the staff nurse in for an interview to investigate the problem and possible solutions
• D. Assign a mentor to assist the staff member in arriving on time

Correct answer: C

Rationale: The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems. Choice A is incorrect as it immediately involves suspension without investigation or support. Choice B is not the best course of action as it does not involve direct communication with the staff member in question. Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.

4. A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?

• A. Verbal teaching in short sessions throughout the day
• B. Provide a pre-operative booklet in Braille
• C. Provide an audio recording for the client
• D. Have the blind patient's family member assist with the instruction

Correct answer: A

Rationale: For a blind patient scheduled for surgery the following morning, the best teaching strategy would be verbal teaching in short sessions throughout the day. Providing information in smaller amounts makes it easier to retain, and one-on-one teaching is most effective. Choice B, providing a pre-operative booklet in Braille, may not be as practical for last-minute teaching. Choice C, providing an audio recording, may not allow for immediate interaction and clarification. Choice D, having a family member instruct the patient, may not ensure the accuracy and clarity of the information provided.

5. A mother who has never breastfed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:

• A. The baby will eventually take to the breast.
• B. I can prepare a bottle if you want to try that.
• C. A small amount of weight loss in the first few days is normal.
• D. I can arrange for the charge nurse to come and talk to you about breastfeeding.

Correct answer: C

Rationale: The correct answer is 'A small amount of weight loss in the first few days is normal.' It is important to reassure the mother that a small amount of weight loss, such as 5-10% of birth weight, in the first few days of life is considered normal for newborns. This reassurance helps alleviate the mother's concerns. Option A is incorrect because it does not address the concern about weight loss; it focuses more on the baby eventually latching on. Option B is not recommended as the first solution for breastfeeding issues, as introducing a bottle early on may lead to nipple confusion. Option D involves escalating the situation to the charge nurse when it can be addressed by providing appropriate information and support directly, making it less necessary in this scenario where reassurance and education are key.

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