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 assessing a client who is receiving digoxin for heart failure. Which of the following findings should the nurse report to the provider?

• A. Heart rate 68/min.
• B. Blood pressure 110/70 mm Hg.
• C. Vision changes.
• D. Respiratory rate 18/min.

Correct answer: C

Rationale: Corrected Rationale: Vision changes are a common sign of digoxin toxicity, which can be serious and should be reported to the provider immediately. Changes in heart rate, blood pressure, or respiratory rate are not typically associated with digoxin toxicity. Therefore, the nurse should prioritize reporting vision changes to ensure prompt assessment and intervention.

3. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Serous drainage on the dressing
• C. Temperature 37.3°C (99.1°F)
• D. Calf pain on dorsiflexion

Correct answer: D

Rationale: The correct answer is D. Calf pain on dorsiflexion following knee surgery may indicate a complication such as deep vein thrombosis, which is a serious condition requiring medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal range for a client post knee surgery and do not typically indicate immediate complications that require urgent reporting.

4. A client has a chest tube. Which of the following interventions should the nurse include?

• A. Clamp the chest tube for 15 minutes every 2 hours.
• B. Maintain the drainage system below the client's chest.
• C. Strip the chest tube every 2 hours.
• D. Keep the collection device at the level of the client's chest.

Correct answer: B

Rationale: Maintaining the chest tube drainage system below the client's chest level is crucial to ensure proper drainage and prevent complications. Clamping the chest tube can lead to a tension pneumothorax, stripping the chest tube is an outdated practice that can cause damage to the tissues, and keeping the collection device at the level of the client's chest can impede proper drainage and lead to fluid accumulation.

5. A nurse is reviewing the laboratory results of a client who is at 36 weeks of gestation. The nurse should report which of the following laboratory results to the provider?

• A. Hemoglobin 11.2 g/dL
• B. Platelet count 148,000/mm3
• C. Leukocyte count 9,000/mm3
• D. Blood glucose 80 mg/dL

Correct answer: A

Rationale: A hemoglobin level of 11.2 g/dL is below the normal range for a client who is 36 weeks gestation and should be reported to the provider.

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