Nursing Elites

1. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Redness and warmth in the calf
• C. Oxygen saturation of 95%
• D. Temperature of 37.3°C (99.1°F)

Correct answer: B

Rationale: Redness and warmth in the calf can indicate a blood clot, specifically deep vein thrombosis (DVT), which is a serious complication post hip arthroplasty. The warmth and redness are signs of inflammation due to the clot formation. DVT can lead to a pulmonary embolism if not addressed promptly. Monitoring for this complication is crucial in postoperative care. Elevated heart rate, oxygen saturation within normal limits, and a slightly elevated temperature are common findings postoperatively and may not be alarming in the absence of other concerning symptoms.

2. What is the initial action a healthcare provider should take for a patient with chest pain?

• A. Administer oxygen
• B. Administer nitroglycerin
• C. Administer morphine
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial action for a patient with chest pain is to administer oxygen. Chest pain can be caused by insufficient oxygenation, and providing oxygen helps alleviate the pain by increasing oxygen levels in the blood. Administering nitroglycerin or morphine may be appropriate based on the underlying cause of the chest pain, but oxygen should be given first to ensure the patient's oxygen supply is adequate. Surgery is not typically the initial intervention for chest pain.

3. What is the appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Encourage ambulation
• C. Apply compression stockings
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Anticoagulants help prevent further clot formation in patients with suspected DVT. Encouraging ambulation can be beneficial in preventing DVT but is not the immediate intervention for a suspected case. Compression stockings are more for DVT prevention rather than treatment. Monitoring oxygen saturation is important in assessing respiratory function but is not the primary intervention for suspected DVT.

4. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30 degrees.
• B. Check gastric residual volumes every 4 hours.
• C. Administer the feeding at room temperature.
• D. Flush the feeding tube with 20 mL of water every 8 hours.

Correct answer: B

Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.

5. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse include?

• A. The cord stump will fall off in 5 days.
• B. Contact the provider if the cord stump turns black.
• C. Clean the base of the cord with hydrogen peroxide daily.
• D. Keep the cord stump dry until it falls off.

Correct answer: D

Rationale: The correct instruction for cord care is to keep the cord stump dry until it falls off. This helps prevent infection and promotes healing. Choice A is incorrect because the timing of when the cord stump falls off can vary, usually between 1-3 weeks. Choice B is incorrect as a black cord stump can be a normal part of the healing process, so it is unnecessary to contact the provider for this reason. Choice C is incorrect because cleaning the cord with hydrogen peroxide daily is not recommended as it can delay healing and cause irritation.

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