Nursing Elites

1. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Apply heat to the incision site.
• B. Keep the client's knee flexed while in bed.
• C. Place a pillow under the client's knee while in bed.
• D. Place a pillow under the client's lower legs.

Correct answer: D

Rationale: Placing a pillow under the client's lower legs is the correct intervention because it helps prevent pressure on the incision site and promotes circulation. Elevating the lower legs also aids in reducing swelling and improving blood flow. Applying heat to the incision site (Choice A) is contraindicated in the early postoperative period as it can increase inflammation and the risk of infection. Keeping the client's knee flexed while in bed (Choice B) may lead to contractures or limited extension of the knee joint. Placing a pillow under the client's knee (Choice C) may cause hyperextension of the knee, which is also not recommended post knee arthroplasty.

2. While caring for a client receiving a blood transfusion who reports chills, which action should the nurse take first?

• A. Stop the transfusion.
• B. Administer acetaminophen as prescribed.
• C. Notify the provider.
• D. Check the client's blood pressure.

Correct answer: A

Rationale: The correct action for the nurse to take first when a client reports chills during a blood transfusion is to stop the transfusion. Chills can indicate a transfusion reaction, which is a potentially serious situation. Stopping the transfusion immediately is crucial to prevent further complications. Administering acetaminophen or checking the client's blood pressure can come after ensuring the safety of the client by stopping the transfusion. Notifying the provider is important, but the immediate priority is to stop the transfusion.

3. A client receiving radiation therapy for breast cancer may experience which of the following side effects that the nurse should monitor for?

• A. Fatigue
• B. Nausea
• C. Skin irritation
• D. Weight gain

Correct answer: C

Rationale: During radiation therapy for breast cancer, one common side effect is skin irritation due to the impact of radiation on the skin cells. This side effect should be closely monitored by the nurse. Fatigue may also occur as a side effect of radiation therapy, but skin irritation is more specific to the treatment area and is a priority in this case. Nausea and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices.

4. A healthcare provider is reviewing the medical record of a client who has Cushing's disease. Which of the following findings should the healthcare provider expect?

• A. Decreased serum glucose level
• B. Increased lymphocyte count
• C. Increased serum potassium level
• D. Decreased serum sodium level

Correct answer: C

Rationale: In Cushing's disease, there is increased cortisol production, which can lead to various metabolic disturbances. One of the common findings is an increased serum potassium level. The other options are incorrect because Cushing's disease typically causes hyperglycemia, not decreased serum glucose levels (A), lymphocytopenia, not increased lymphocyte count (B), and hyponatremia, not decreased serum sodium level (D).

5. What is the priority nursing assessment for a patient who has just returned from surgery?

• A. Monitor respiratory rate
• B. Monitor blood pressure
• C. Check the surgical site
• D. Monitor heart rate

Correct answer: A

Rationale: The correct answer is to monitor the patient's respiratory rate. This assessment is essential as it ensures that the patient is breathing adequately post-surgery. Maintaining a patent airway and adequate oxygenation are the top priorities in the immediate postoperative period. Monitoring blood pressure, checking the surgical site, or monitoring heart rate are important assessments but are not the priority immediately upon the patient's return from surgery.

Similar Questions