Nursing Elites

1. A client is post-operative day one following an open cholecystectomy. The nurse notices the client's drainage from the T-tube is dark green. What is the most appropriate action for the nurse to take?

• A. Document the finding as normal.
• B. Notify the healthcare provider immediately.
• C. Decrease the suction on the T-tube.
• D. Flush the T-tube with saline to ensure patency.

Correct answer: A

Rationale: Dark green drainage from a T-tube after a cholecystectomy is bile, which is an expected finding. Bile is normally dark green in color. It is important for the nurse to recognize this as a normal post-operative occurrence and document the finding. There is no need to notify the healthcare provider immediately as this finding is an anticipated part of the client's recovery. Decreasing the suction on the T-tube or flushing it with saline is unnecessary and may not be indicated based on the color of the drainage. Therefore, the most appropriate action for the nurse to take is to document the dark green drainage as a normal finding.

2. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?

• A. Avoid crossing your legs at the knees or ankles.
• B. Do not sleep on the side of the hip that was operated on.
• C. Sit in high chairs and keep your knees higher than your hips.
• D. Do not bend forward at the waist to pick up objects.

Correct answer: A

Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.

3. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?

• A. Using a sterile technique
• B. Ensuring correct placement of the CVC
• C. Flushing the CVC with saline after administration
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.

4. During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse take?

• A. Record the findings and report the symptoms to the charge nurse
• B. Ask the family members to visit more often to stimulate the patient
• C. Motivate the client by offering favorite foods as a prize
• D. Withhold any medications that may cause side effects

Correct answer: A

Rationale: The practical nurse should record the findings and report the symptoms to the charge nurse. These behaviors may indicate a serious underlying condition such as depression or physical illness. By reporting to the charge nurse, the client can receive appropriate assessment and intervention promptly. Choice B is incorrect as family visits may not address the root cause of the symptoms. Choice C is incorrect as it oversimplifies the situation and may not be effective in addressing the underlying issue. Choice D is incorrect because withholding medications without proper assessment and guidance can be harmful to the client's health.

5. A client with a recent total knee replacement is scheduled for physical therapy. The client refuses to participate, stating that the pain is too intense. What should the nurse do first?

• A. Administer the prescribed analgesic and encourage participation after it takes effect.
• B. Reschedule the physical therapy session for later in the day.
• C. Explain the importance of physical therapy for recovery.
• D. Notify the physical therapist of the client's refusal.

Correct answer: A

Rationale: Administering pain medication before physical therapy helps manage the pain, making it easier for the client to participate in the necessary exercises to improve recovery and prevent complications such as joint stiffness. Choice B is not the first step as addressing the pain should take precedence. Choice C is important but should come after managing the pain to facilitate participation. Choice D involves another healthcare provider and is not the immediate action needed in this situation.

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