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. How should fluid overload in a patient with heart failure be managed?

• A. Administer diuretics
• B. Increase fluid intake
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

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 client has a nasogastric tube and is receiving intermittent enteral feedings. Which of the following actions should the nurse take to prevent aspiration?

• A. Administer a bolus feeding over 10 minutes.
• B. Elevate the head of the bed to 45 degrees during feedings.
• C. Flush the tube with 10 mL of sterile water before feedings.
• D. Position the client on the left side during feedings.

Correct answer: B

Rationale: To prevent aspiration in clients with a nasogastric tube receiving intermittent enteral feedings, the nurse should elevate the head of the bed to 45 degrees during feedings. This position helps reduce the risk of regurgitation and aspiration of the feeding contents. Administering a bolus feeding over 10 minutes (choice A) may not prevent aspiration as effectively as elevating the head of the bed. Flushing the tube with sterile water before feedings (choice C) is important for tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (choice D) is not the recommended action to prevent aspiration; elevating the head of the bed is more effective.

5. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

• A. A 6-year-old client with a dislocated left shoulder
• B. A 26-year-old client with sickle cell disease and severe joint pain
• C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
• D. A 50-year-old client with slurred speech, disorientation, and headache

Correct answer: D

Rationale: The correct answer is D. A client presenting with symptoms of a stroke, such as slurred speech, disorientation, and headache, requires immediate attention due to the possibility of a neurological emergency. Choices A, B, and C, although concerning, do not present with symptoms as urgent as those of a potential stroke. Dislocated shoulder, sickle cell disease with joint pain, and confusion with febrile illness can be addressed after ensuring the client with stroke-like symptoms receives prompt evaluation and intervention.

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