Nursing Elites

1. A nurse is providing discharge instructions to a client who is postoperative following a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?

• A. I will avoid crossing my legs when sitting.
• B. I will use a raised toilet seat.
• C. I will sleep on my affected side.
• D. I will perform leg exercises every hour while awake.

Correct answer: C

Rationale: The correct answer is C. Sleeping on the affected side could increase the risk of dislocation following a hip arthroplasty. It is essential for the client to avoid sleeping on the surgical side to prevent complications. Choices A, B, and D are correct statements that promote proper postoperative care and reduce the risk of complications. Avoiding crossing legs when sitting, using a raised toilet seat for proper positioning, and performing leg exercises regularly help in the recovery process and prevent complications.

2. A client has a new prescription for levothyroxine. Which of the following findings should the nurse monitor for as a potential adverse effect of the medication?

• A. Increased heart rate.
• B. Weight loss.
• C. Hyperthermia.
• D. Decreased deep-tendon reflexes.

Correct answer: A

Rationale: Corrected Rationale: An increased heart rate is a common adverse effect of levothyroxine due to its role in boosting metabolism. Choice B, weight loss, is actually a therapeutic effect of levothyroxine as it helps in managing hypothyroidism by increasing the metabolic rate. Hyperthermia (Choice C) is not a typical adverse effect of levothyroxine. Decreased deep-tendon reflexes (Choice D) are not associated with levothyroxine use.

3. A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the healthcare professional take to identify the client?

• A. Match the client's identification band with the number on the blood unit
• B. Confirm the provider's prescription matches the number on the blood component
• C. Ask the client to state their blood type and confirm the date of their last blood donation
• D. Ensure that the client's identification band matches the number on the blood unit

Correct answer: D

Rationale: Ensuring that the client's identification band matches the number on the blood unit is crucial for correct identification. This action helps prevent errors by confirming that the blood product is indeed intended for the specific client. Matching the client's blood type with type and cross-match specimens (Choice A) is important for compatibility but does not directly verify the client's identity. Confirming the provider's prescription (Choice B) is relevant but does not ensure the correct identification of the client. Asking the client to state their blood type and confirm the date of their last blood donation (Choice C) relies on the client's memory and verbal confirmation, which may not be accurate or reliable for identification purposes.

4. A nurse is caring for a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. JVD.
• C. Crackles in the lungs.
• D. Hypotension.

Correct answer: B

Rationale: The correct answer is B: JVD. Jugular venous distention (JVD) is a common finding in right-sided heart failure due to fluid overload. This occurs because the right side of the heart is unable to effectively pump blood, leading to congestion and increased venous pressure, which is manifested as JVD. Choices A, C, and D are incorrect. Peripheral edema (choice A) is more commonly associated with left-sided heart failure. Crackles in the lungs (choice C) are indicative of pulmonary edema, often seen in left-sided heart failure. Hypotension (choice D) is not typically seen in right-sided heart failure, as it is more commonly associated with conditions like shock or severe dehydration.

5. A healthcare professional is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?

• A. PaO2 level of 89 mm Hg
• B. PaCO2 level of 55 mm Hg
• C. HCO3 level of 25 mEq/L
• D. pH level of 7.37

Correct answer: B

Rationale: The correct answer is B. A high PaCO2 level (55 mm Hg) in a client with chronic emphysema suggests respiratory acidosis, which requires further treatment. In chronic emphysema, impaired gas exchange leads to elevated carbon dioxide levels in the blood. Option A (PaO2 level of 89 mm Hg) is near the normal range and does not indicate immediate treatment. Option C (HCO3 level of 25 mEq/L) and option D (pH level of 7.37) are within normal limits and do not suggest the need for further treatment in this context.

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