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. What is the appropriate action for a patient experiencing chest pain?

• A. Administer aspirin
• B. Reposition the patient
• C. Check oxygen saturation
• D. Prepare for surgery

Correct answer: A

Rationale: The correct action for a patient experiencing chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation in patients with chest pain, as it has antiplatelet effects. Repositioning the patient may not address the underlying cause of the chest pain. Checking oxygen saturation is important but not the initial priority in this scenario. Surgery is not typically the first-line treatment for chest pain without further assessment and diagnostic procedures.

3. A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Take this medication with food to reduce stomach upset.
• B. Inject this medication into the muscle.
• C. Massage the injection site after administering the medication.
• D. Inject this medication into the abdomen.

Correct answer: D

Rationale: The correct answer is D because enoxaparin should be injected into the abdomen to ensure proper absorption. Choice A is incorrect as enoxaparin should not be taken with food. Choice B is incorrect as enoxaparin should be injected subcutaneously, not into the muscle. Choice C is incorrect as massaging the injection site after administering enoxaparin is not recommended.

4. A patient is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

• A. Prime IV tubing with 0.9% sodium chloride
• B. Use a 24-gauge IV catheter
• C. Obtain filterless IV tubing
• D. Place blood in the warmer for 1 hour

Correct answer: A

Rationale: Priming the IV tubing with 0.9% sodium chloride is crucial before administering packed RBCs as it prevents hemolysis and ensures the safe transfusion of blood. Using a smaller 20- to 22-gauge IV catheter is recommended for packed RBCs to prevent hemolysis due to the small tubing size and faster flow rate. Obtaining filterless IV tubing is incorrect as blood products should be administered through a specialized filter to prevent potential clots or contaminants from reaching the patient. Placing blood in the warmer for an hour is unnecessary and could lead to overheating, potentially causing harm to the patient.

5. A client with schizophrenia is experiencing delusions. Which of the following actions should the nurse take?

• A. Encourage the client to discuss the delusions.
• B. Tell the client that the delusions are not real.
• C. Avoid discussing the delusions with the client.
• D. Challenge the client's delusions directly.

Correct answer: B

Rationale: Telling the client that their delusions are not real is the most appropriate action as it helps ground them in reality without reinforcing the delusion. Encouraging the client to discuss the delusions (choice A) may further validate or intensify the delusions. Avoiding discussing the delusions (choice C) may lead to the client feeling isolated and unheard. Challenging the client's delusions directly (choice D) can escalate the situation and cause distress to the client.

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