Nursing Elites

1. A client is post-operative day two from a total hip arthroplasty. The nurse notices the surgical wound is red and warm to the touch. What is the most appropriate action?

• A. Apply an ice pack to the incision site.
• B. Monitor the client's temperature.
• C. Document the findings and continue to monitor.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct action when a nurse notices redness and warmth at the surgical wound post total hip arthroplasty is to notify the healthcare provider. These signs may indicate an infection, and prompt evaluation by the healthcare provider is crucial to initiate appropriate treatment. Applying an ice pack (Choice A) may not address the underlying issue of a potential infection. Monitoring the client's temperature (Choice B) is important but not the priority when signs of infection are present. Documenting the findings and continuing to monitor (Choice C) is necessary but should be accompanied by notifying the healthcare provider for further assessment and intervention.

2. A client is post-operative day two from an abdominal surgery and reports feeling weak and lightheaded when attempting to get out of bed. What is the nurse's priority action?

• A. Encourage the client to drink fluids.
• B. Assist the client back to bed and monitor vital signs.
• C. Administer a prescribed antiemetic.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: The nurse's priority action should be to assist the client back to bed and monitor vital signs. The client's symptoms of feeling weak and lightheaded could indicate potential issues like hypotension or dehydration, which need to be assessed promptly. Encouraging fluids (Choice A) could be beneficial but is not the immediate priority. Administering an antiemetic (Choice C) may not address the underlying cause of the client's symptoms. Notifying the healthcare provider (Choice D) can be done after the client has been stabilized and assessed.

3. How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?

• A. The goals set by the client
• B. The learning level of the client
• C. Assessing the home environment
• D. The distractions in the client's home

Correct answer: C

Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.

4. While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on these observations, what documentation should the PN include?

• A. Impaired verbalization
• B. Depressed mood
• C. Flat affect
• D. Diminished LOC

Correct answer: C

Rationale: The correct answer is C: 'Flat affect.' Flat affect refers to a lack of emotional expression, which the PN observed in the client. This observation is significant as it can provide valuable information for the client's mental health assessment and subsequent care planning. Choice A, 'Impaired verbalization,' does not capture the lack of emotional expression seen in the client. Choice B, 'Depressed mood,' may not accurately reflect the observed behavior of the client. Choice D, 'Diminished LOC,' pertains to the level of consciousness, which was not indicated as being a concern in the scenario provided.

5. Which of the following is a common side effect of opioid analgesics that the nurse should monitor for in patients?

• A. Diarrhea
• B. Hypertension
• C. Constipation
• D. Bradycardia

Correct answer: C

Rationale: Constipation is a common side effect of opioid analgesics due to the slowing of gastrointestinal motility. Opioids bind to receptors in the gastrointestinal tract, leading to decreased peristalsis and increased water absorption, resulting in constipation. Monitoring for constipation is crucial to prevent discomfort or complications like bowel obstruction. Diarrhea (Choice A) is not a common side effect of opioid analgesics. Hypertension (Choice B) and Bradycardia (Choice D) are not typically associated with opioid use.

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