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 the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.

3. A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?

• A. Reassure the client of the surgeon's skill
• B. The surgeon will answer your questions before surgery
• C. Tell the client surgery is necessary
• D. Encourage the client to seek a second opinion

Correct answer: B

Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.

4. A client is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates understanding?

• A. I can change my living will whenever I want.
• B. I do not need a living will if I have a durable power of attorney.
• C. My family will make decisions for me if I am unable to.
• D. I need a living will only if I am seriously ill.

Correct answer: A

Rationale: The correct answer is A because the client understanding that they can change their living will whenever they want shows comprehension of advance directives. Choices B, C, and D are incorrect: B is inaccurate as both documents serve different purposes; C may not always be the case based on the client's wishes and legal documents; D is incorrect because a living will is not only for serious illness but also for end-of-life care decisions.

5. When admitting a client with meningococcal meningitis, what should the nurse do first?

• A. Administer antibiotics
• B. Place the client on droplet precautions
• C. Perform a lumbar puncture
• D. Initiate seizure precautions

Correct answer: B

Rationale: When admitting a client with meningococcal meningitis, the nurse's priority should be to place the client on droplet precautions. This is crucial to prevent the spread of the infection to others. Administering antibiotics, performing a lumbar puncture, and initiating seizure precautions are important interventions but should come after implementing droplet precautions to ensure the safety of both the client and others.

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