Nursing Elites

1. A nurse is caring for a client who is undergoing surgery for a hip fracture. What is a priority intervention to reduce the risk of postoperative complications?

• A. Encourage early ambulation
• B. Provide intravenous antibiotics
• C. Apply anti-embolism stockings
• D. Place a Foley catheter to monitor output

Correct answer: A

Rationale: Encouraging early ambulation is crucial in reducing the risk of postoperative complications, such as blood clots and pneumonia. Early mobilization helps prevent complications like deep vein thrombosis and pneumonia by promoting circulation and preventing respiratory complications. Providing intravenous antibiotics (Choice B) is important for preventing infections but is not the priority immediately post-surgery. Applying anti-embolism stockings (Choice C) is beneficial in preventing venous thromboembolism but does not address the immediate need for mobility. Placing a Foley catheter (Choice D) may be necessary during surgery but is not a priority intervention to reduce postoperative complications related to immobility.

2. A nurse is assessing a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?

• A. Irrigate the catheter with normal saline
• B. Notify the provider
• C. Administer prescribed antibiotics
• D. Assess for signs of infection

Correct answer: B

Rationale: When a client reports pain at the site of an indwelling urinary catheter, the nurse's first action should be to notify the provider. This is important to ensure timely assessment and intervention by the healthcare provider. Irrigating the catheter with normal saline or administering antibiotics should not be done without provider's orders as it may mask symptoms or lead to inappropriate treatment. Assessing for signs of infection is important but should come after notifying the provider, who can guide further assessment and treatment.

3. A healthcare professional is reviewing the laboratory values of a client who is experiencing fluid volume deficit (FVD). What finding should the professional expect?

• A. Decreased hematocrit
• B. Increased hematocrit
• C. Decreased white blood cell count
• D. Increased red blood cell count

Correct answer: B

Rationale: The correct answer is 'Increased hematocrit.' In fluid volume deficit (FVD), there is a decrease in the amount of fluid in the blood vessels, leading to hemoconcentration. This results in an increase in hematocrit levels. Choices A, C, and D are incorrect because a decrease in hematocrit, decrease in white blood cell count, and an increase in red blood cell count are not typically seen in fluid volume deficit.

4. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?

• A. Nutritional status
• B. Client's response to pain medication
• C. Daily vital signs
• D. Most recent lab results

Correct answer: B

Rationale: The correct answer is B: Client's response to pain medication. When transferring a client to another unit, it is crucial to communicate how the client is responding to pain medication to ensure continuity of care and appropriate pain management. While nutritional status, daily vital signs, and most recent lab results are important aspects of the client's care, the client's response to pain medication directly impacts their comfort and well-being during the transfer process.

5. A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?

• A. Steamed carrots
• B. Orange slices
• C. Mashed potatoes
• D. Baked chicken

Correct answer: B

Rationale: The correct answer is B: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices fall into this category due to their texture and potential choking hazard. Steamed carrots, mashed potatoes, and baked chicken are typically suitable for a mechanical soft diet as they can be easily mashed or cut into small, manageable pieces for consumption.

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