Nursing Elites

1. A client had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?

• A. Maintain foam wedge between legs
• B. Monitor for shortening of the affected leg
• C. Encourage use of elastic stockings
• D. Avoid flexing the hips more than 60 degrees

Correct answer: A

Rationale: The correct answer is to maintain a foam wedge between the legs. This intervention helps prevent hip dislocation by maintaining proper leg alignment after surgery. Monitoring for shortening of the affected leg (choice B) is not directly related to preventing dislocation. Encouraging the use of elastic stockings (choice C) is more related to preventing deep vein thrombosis rather than dislocation. Avoiding flexing the hips more than 60 degrees (choice D) is important post-surgery, but it is not the most direct intervention to prevent dislocation.

2. When the nurse discovers a patient on the floor, and the patient states, 'I fell out of bed,' the nurse assesses the patient and then places the patient back in bed. What action should the nurse take next?

• A. Re-assess the patient.
• B. Complete an incident report.
• C. Notify the healthcare provider.
• D. Do nothing, as no harm has occurred.

Correct answer: C

Rationale: After a patient has fallen, it is crucial to notify the healthcare provider. The provider needs to be informed so that further assessment, evaluation, or intervention can be carried out to ensure the patient's safety and well-being. Re-assessing the patient (Choice A) is important but notifying the healthcare provider takes precedence. Completing an incident report (Choice B) is necessary but should follow notifying the healthcare provider. Doing nothing (Choice D) is not appropriate as patient safety and potential underlying issues need to be addressed promptly.

3. A client with a new prescription for sumatriptan tablets to treat migraine headaches should report which of the following symptoms to the nurse?

• A. Chew the tablet well before swallowing
• B. Report swelling of the eyelids after dosage
• C. Repeat dose in 1 hour for unrelieved headache
• D. Take daily to prevent headaches

Correct answer: B

Rationale: The correct answer is B because swelling of the eyelids is a side effect of sumatriptan tablets that requires immediate reporting to the healthcare provider to prevent further complications. Choices A, C, and D are incorrect. Chewing the tablet well before swallowing is not necessary for sumatriptan tablets. Repeating the dose in 1 hour for unrelieved headache is incorrect as this medication should not be repeated within 24 hours. Taking sumatriptan daily for headache prevention is also incorrect as it is used for acute treatment, not prevention.

4. Which action by the nurse represents the ethical principle of beneficence?

• A. Ensuring all clients are treated fairly
• B. Preventing harm by providing accurate information
• C. Allowing the client to refuse treatment
• D. Ensuring the client's family agrees with the treatment

Correct answer: B

Rationale: The correct answer is B. Beneficence is the ethical principle of doing good or acting in the best interest of the client. Preventing harm by providing accurate information and necessary care aligns with the principle of beneficence, as it focuses on promoting the well-being and safety of the client. Choices A, C, and D do not directly reflect the concept of beneficence. Ensuring all clients are treated fairly relates more to justice, allowing the client to refuse treatment pertains to autonomy, and ensuring the client's family agrees with the treatment involves collaboration and communication but not specifically beneficence.

5. A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin IV every 8 hours. Which of the following serum laboratory results should the nurse report to the provider before administering the gentamicin?

• A. Hematocrit 45%
• B. Sodium 140 mEq/L
• C. Creatinine 2.4 mg/dL
• D. Potassium 4.0 mEq/L

Correct answer: C

Rationale: An elevated creatinine level indicates potential kidney dysfunction, which is crucial when administering gentamicin as it can be nephrotoxic. Reporting a high creatinine level to the provider is essential to prevent further kidney damage. Choice A (Hematocrit 45%) is within the normal range and not directly related to gentamicin administration. Choice B (Sodium 140 mEq/L) and Choice D (Potassium 4.0 mEq/L) are also within normal limits and do not directly impact the administration of gentamicin.

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