Nursing Elites

1. A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?

• A. Encourage the client to bend at the waist
• B. Maintain the client in a high-Fowler's position
• C. Place a pillow between the client's legs
• D. Avoid placing a pillow under the client's knees

Correct answer: C

Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.

2. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Palpation, Inspection, Observation, Auscultation
• C. Percussion, Inspection, Auscultation, Palpation
• D. Inspection, Percussion, Auscultation, Palpation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.

3. What is the priority nursing action for a dehydrated client who needs fluids?

• A. Administer antiemetics to prevent vomiting
• B. Monitor electrolyte levels frequently
• C. Administer oral rehydration solutions
• D. Insert an NG tube for fluid administration

Correct answer: B

Rationale: The correct answer is to monitor electrolyte levels frequently. When a client is dehydrated and needs fluids, it is essential to monitor electrolyte levels to prevent complications such as electrolyte imbalances. Administering antiemetics to prevent vomiting (Choice A) may be necessary but is not the priority when addressing dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels takes precedence to ensure proper hydration. Inserting an NG tube for fluid administration (Choice D) is invasive and not typically the first-line approach for managing dehydration.

4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?

• A. Monitor the client's electrolyte levels
• B. Change the TPN tubing every 24 hours
• C. Monitor blood glucose levels every 4 hours
• D. Administer insulin as prescribed

Correct answer: B

Rationale: The correct answer is B. Changing the TPN tubing every 24 hours is crucial in preventing infection by reducing the risk of bacterial contamination. Monitoring electrolyte levels (choice A) is essential but not directly related to preventing TPN-related infections. Monitoring blood glucose levels (choice C) is important for clients receiving TPN, but it is more related to glycemic control than infection prevention. Administering insulin as prescribed (choice D) is necessary for clients with diabetes but is not directly linked to preventing TPN-related infections.

5. A client with type 2 diabetes mellitus is being taught about insulin administration by a nurse. Which of the following instructions should the nurse include?

• A. Inject insulin into the muscle
• B. Rotate injection sites with each dose
• C. Store insulin at room temperature
• D. Massage the injection site after administration

Correct answer: B

Rationale: The correct instruction that the nurse should include is to rotate injection sites with each dose. This practice is essential to prevent tissue damage and ensure proper insulin absorption. Option A is incorrect because insulin should not be injected into the muscle, but rather into the subcutaneous tissue. Option C is incorrect as insulin should be stored in the refrigerator to maintain its effectiveness. Option D is incorrect as massaging the injection site after administration can lead to faster absorption and potentially hypoglycemia.

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