Nursing Elites

1. A patient is 1 day postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

• A. Administer aspirin for pain management.
• B. Keep the affected leg in a dependent position.
• C. Flex the affected knee for 2 to 3 minutes every hour.
• D. Apply ice packs to the affected knee.

Correct answer: D

Rationale: The correct action for a client 1 day postoperative following a total knee arthroplasty is to apply ice packs to the affected knee. Ice packs help reduce swelling and pain in such clients. Administering aspirin is contraindicated due to the risk of bleeding postoperatively. Keeping the affected leg in a dependent position can impair circulation and increase the risk of complications. Flexing the affected knee for extended periods can strain the surgical site and hinder the healing process.

2. A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Blood pressure 110/70 mm Hg
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: A low urine output of 20 mL/hr, less than the expected 30 mL/hr or more, could indicate renal impairment or inadequate fluid status postoperatively. In this scenario, early detection and intervention are crucial to prevent further complications. The other findings - heart rate of 88/min, pain rating of 4, and blood pressure of 110/70 mm Hg - are within normal limits for a client 2 hr postoperative following an inguinal hernia repair and do not raise immediate concerns.

3. A nurse is caring for a client who has a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?

• A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
• B. Increased urinary output.
• C. Blood pressure of 118/78 mm Hg.
• D. Decreased peripheral edema.

Correct answer: A

Rationale: The correct answer is A. Weight loss of 0.5 kg (1.1 lb) in 24 hours is an indication that furosemide is effectively reducing fluid retention. This medication works by promoting diuresis, resulting in increased urine output, which could lead to weight loss. While increased urinary output (choice B) is a common effect of furosemide, weight loss is a more specific indicator of its effectiveness. Blood pressure (choice C) and decreased peripheral edema (choice D) can be influenced by various factors and are not direct indicators of furosemide's effectiveness in reducing fluid retention.

4. A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. Take this medication in the evening.
• C. You should avoid taking this medication with dairy products.
• D. You should monitor for signs of infection while taking this medication.

Correct answer: D

Rationale: The correct answer is D: "You should monitor for signs of infection while taking this medication." When a client is prescribed prednisone, it is essential to monitor for signs of infection due to the immunosuppressive effects of corticosteroids. Choices A, B, and C are incorrect because prednisone does not need to be taken on an empty stomach, at a specific time of day, or avoided with dairy products.

5. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

• A. Provide reality orientation throughout the day.
• B. Limit the client's choices to prevent decision fatigue.
• C. Encourage the client to participate in group therapy.
• D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

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