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1. A nurse is caring for a client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Cross the client's legs at the knees
- B. Maintain the client's legs in a neutral position
- C. Avoid placing a pillow under the client's knees
- D. Elevate the client's legs
Correct answer: C
Rationale: The correct action to prevent dislocation of the prosthesis after hip replacement surgery is to avoid placing a pillow under the client's knees. Placing a pillow can cause hip adduction, leading to dislocation. Crossing the client's legs at the knees and elevating the client's legs can also increase the risk of hip dislocation. Maintaining the client's legs in a neutral position is important to prevent complications.
2. What is an important consideration when administering a blood transfusion?
- A. Ensure the blood is compatible with the recipient's blood type
- B. Warm the blood to body temperature before administration
- C. Check the blood for clots before administration
- D. Ensure the recipient eats before the transfusion
Correct answer: A
Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.
3. A client has expressive aphasia following a stroke. Which of the following methods should be used when communicating with the client?
- A. Speak slowly
- B. Provide written instructions
- C. Use a picture board
- D. Write on a whiteboard
Correct answer: C
Rationale: When communicating with a client who has expressive aphasia, using a picture board is an effective method as it provides an alternative means of communication. Option A, speaking slowly, may not improve understanding for someone with expressive aphasia. Option B, providing written instructions, may also be challenging for individuals with this condition. Option D, writing on a whiteboard, may not be as helpful as using a picture board in facilitating communication for a client with expressive aphasia.
4. What are the complications of untreated fluid overload?
- A. Pulmonary edema and congestive heart failure
- B. Hypertension and electrolyte imbalance
- C. Liver failure and electrolyte imbalance
- D. Pulmonary embolism and dehydration
Correct answer: A
Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.
5. What is the most important step when preparing to administer a blood transfusion?
- A. Check if the client has a fever
- B. Ensure the blood type is compatible with the client
- C. Administer the blood via IV push
- D. Ensure the blood is warmed to body temperature
Correct answer: B
Rationale: The correct answer is B: Ensure the blood type is compatible with the client. This is the most crucial step in preparing for a blood transfusion to prevent severe transfusion reactions. Checking the client for a fever (Choice A) is important but not the most critical step. Administering blood via IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow drip. Warming the blood to body temperature (Choice D) is not a standard practice and can lead to hemolysis, making it an incorrect choice.
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