Nursing Elites

1. A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

• A. Position the client supine with a pillow between the legs.
• B. Place an abduction pillow between the client's legs.
• C. Place a pillow under the client's knees.
• D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

2. A nurse is caring for a client who has Raynaud's disease. What intervention should the nurse implement?

• A. Provide information about stress management.
• B. Maintain a cool temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: The correct intervention for a client with Raynaud's disease is to provide information about stress management. Stress management techniques can help reduce the frequency and severity of Raynaud's episodes. Choice B is incorrect because maintaining a cool temperature can exacerbate symptoms in individuals with Raynaud's disease. Choice C is incorrect as epinephrine is not typically used for Raynaud's disease. Choice D is incorrect as glucocorticoid steroids are not the first-line treatment for Raynaud's disease.

3. A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?

• A. Nuchal rigidity.
• B. Flaccid paralysis.
• C. Bradycardia.
• D. Hypothermia.

Correct answer: A

Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.

4. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

• A. Encourage the client to increase fluid intake.
• B. Suction the client every 2 hours.
• C. Perform chest physiotherapy every 8 hours.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

5. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?

• A. Increased appetite
• B. Pallor
• C. Tachycardia
• D. Hypertension

Correct answer: B

Rationale: The correct answer is B: Pallor. Pallor, which is paleness of the skin, is a common sign of anemia due to a decreased number of red blood cells or hemoglobin levels. This results in reduced oxygen-carrying capacity, leading to the paleness of the skin. Choice A, increased appetite, is not typically associated with anemia. Choice C, tachycardia (increased heart rate), can be present in anemia as the body compensates for decreased oxygenation. Choice D, hypertension (high blood pressure), is not a common finding in anemia; instead, low blood pressure may be observed due to decreased blood volume.

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