Nursing Elites

1. A client has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

• A. Apply a fecal collection system
• B. Apply a barrier cream
• C. Cleanse and dry the area
• D. Check the client's perineum

Correct answer: D

Rationale: When a client with major fecal incontinence reports irritation in the perianal area, the nurse's initial action should be to assess the client's perineum to gather more information. By checking the perineum, the nurse can identify the extent and nature of the irritation, allowing for appropriate interventions to be initiated. This assessment is crucial in developing a comprehensive care plan and addressing the client's immediate needs effectively. Applying the nursing process priority-setting framework helps in planning care and prioritizing nursing actions, making assessment the initial step in this scenario. Applying a fecal collection system (choice A) would be premature without assessing the perineal area first. Similarly, applying a barrier cream (choice B) or cleansing and drying the area (choice C) should follow the assessment to ensure appropriate interventions are chosen based on the assessment findings.

2. During postoperative teaching following a hip arthroplasty, which instruction should the nurse include?

• A. Avoid lying on your operative side.
• B. Cross your legs at the ankles only.
• C. Place a pillow between your legs when turning.
• D. Avoid bending your hip more than 120 degrees.

Correct answer: C

Rationale: The correct instruction for the nurse to include during postoperative teaching following a hip arthroplasty is to 'Place a pillow between your legs when turning.' Placing a pillow between the legs when turning is crucial as it helps prevent dislocation of the hip prosthesis. This position aids in maintaining proper alignment and stability, thereby reducing the risk of complications after hip arthroplasty surgery. Choices A, B, and D are incorrect because they do not directly address the specific action needed to protect the hip prosthesis and prevent complications.

3. A client is being assessed for dehydration. Which of the following findings should the nurse expect?

• A. Elevated blood pressure
• B. Increased skin turgor
• C. Dark-colored urine
• D. Bradypnea

Correct answer: C

Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.

4. A client receives discharge teaching on a new prescription for lisinopril. Which of the following instructions should be included?

• A. Avoid foods high in potassium.
• B. Take the medication with food.
• C. Increase your intake of salt.
• D. Take the medication at bedtime.

Correct answer: A

Rationale: The correct instruction that should be included when a client receives discharge teaching on a new prescription for lisinopril is to 'Avoid foods high in potassium.' Lisinopril, an ACE inhibitor, can lead to hyperkalemia by reducing potassium excretion. Therefore, clients taking lisinopril should be advised to avoid foods high in potassium to prevent potential complications associated with elevated potassium levels. Choices B, C, and D are incorrect because taking lisinopril with food, increasing salt intake, or taking the medication at bedtime are not specific instructions related to lisinopril therapy and may not be beneficial or necessary for the client's condition.

5. A client has been prescribed enoxaparin. Which of the following instructions should the nurse include?

• A. You need to obtain routine blood tests to monitor the effects of this medication.
• B. You should administer the medication into your thigh.
• C. You should inject the medication once daily.
• D. You need to use a 1-inch needle to administer the medication.

Correct answer: C

Rationale: The correct instruction to include when educating a client prescribed enoxaparin is to inject the medication once daily. Enoxaparin is typically administered via subcutaneous injection once daily, usually in the abdomen, to prevent blood clots.

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