Nursing Elites

1. 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.

2. Which action should the PN implement when using standard precautions to provide client care?

• A. Apply sterile gloves to obtain a finger stick blood sample
• B. Wear clean exam gloves to perform perineal catheter care
• C. Replace the needle cap after giving an intramuscular injection
• D. Wear a paper gown to prevent transmission of droplet pathogens

Correct answer: B

Rationale: The correct answer is B. When using standard precautions, healthcare providers should wear clean exam gloves to perform perineal catheter care. This approach helps prevent the transmission of pathogens and ensures the safety of both the client and the healthcare provider. Choice A is incorrect because applying sterile gloves for a finger stick blood sample is unnecessary when non-sterile gloves would suffice. Choice C is incorrect because replacing the needle cap after giving an intramuscular injection is not directly related to standard precautions. Choice D is incorrect because wearing a paper gown is not a standard precaution for preventing the transmission of droplet pathogens.

3. Which electrolyte imbalance is most likely to cause cardiac arrhythmias?

• A. Hyperkalemia
• B. Hypocalcemia
• C. Hypernatremia
• D. Hypokalemia

Correct answer: A

Rationale: Hyperkalemia is the correct answer as it can lead to dangerous cardiac arrhythmias due to its effects on the electrical conduction of the heart. High levels of potassium can disrupt the normal electrical activity of the heart, potentially leading to life-threatening arrhythmias. Hypocalcemia (choice B) is not the most likely cause of cardiac arrhythmias compared to hyperkalemia. Hypernatremia (choice C), referring to high sodium levels, is not directly associated with causing cardiac arrhythmias. While hypokalemia (choice D), low potassium levels, can also lead to cardiac arrhythmias, hyperkalemia is the more likely culprit in causing severe disturbances in heart rhythm.

4. According to the principle of asepsis, which situation should the PN consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the PN thinks might have touched hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp table top
• D. An open sterile Foley catheter kit set up on a table at the PN's waist level

Correct answer: A

Rationale: According to the principle of asepsis, the one-inch border around the edges of a sterile field set up in the operating room is considered non-sterile, while the central area remains sterile. Therefore, the PN should consider the situation described in choice A to be sterile. Choice B is incorrect because a glove that may have touched hair is contaminated. Choice C is incorrect as a sterile item placed on a damp surface is considered contaminated. Choice D is incorrect as a sterile kit set up at the PN's waist level is prone to contamination.

5. Which electrolyte imbalance is most commonly associated with seizures?

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

Correct answer: A

Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.

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