Nursing Elites

1. A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

• A. Assess mobility
• B. Monitor vital signs
• C. Provide pain relief
• D. Reinforce discharge teaching

Correct answer: A

Rationale: Assessing mobility should be the nurse's priority as it ensures the client's safety and helps in developing an appropriate care plan. By evaluating the client's ability to move after the knee arthroplasty, the nurse can identify any immediate issues or complications that need to be addressed promptly. Monitoring vital signs, providing pain relief, and reinforcing discharge teaching are important aspects of care but assessing mobility takes precedence in ensuring the client's immediate well-being and identifying any potential risks.

2. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates a hemolytic transfusion reaction?

• A. Chills
• B. Bradycardia
• C. Hypertension
• D. Low back pain

Correct answer: D

Rationale: Low back pain is a classic sign of a hemolytic transfusion reaction and requires immediate intervention. Chills are more commonly associated with a febrile non-hemolytic transfusion reaction. Bradycardia is not a typical sign of a hemolytic transfusion reaction. Hypertension is not a common finding in a hemolytic transfusion reaction.

3. What is the first intervention for a patient in shock?

• A. Administer fluids
• B. Monitor blood pressure
• C. Provide oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.

4. A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?

• A. My son took my wallet to keep track of my spending
• B. My son always cooks my meals for me
• C. My son doesn't want me to drive alone
• D. I exercise every day with my son

Correct answer: A

Rationale: The correct answer is A. Taking away a wallet to control spending is a form of financial maltreatment, which is a common form of abuse among older adults. Choices B, C, and D do not indicate maltreatment; rather, they show examples of care and concern from the son. Cooking meals, preventing the older adult from driving alone, and engaging in daily exercise are positive behaviors.

5. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

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