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 nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

• A. Flush the tube with 30 mL of sterile water before each feeding.
• B. Check for gastric residuals every 4 hours.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Place the client in the left lateral position during feedings.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

3. How should a healthcare provider manage a patient with a history of hypertension who is non-compliant with medication?

• A. Educate the patient on the importance of medication
• B. Reassess the patient in 6 months
• C. Refer the patient to a specialist
• D. Discontinue the medication

Correct answer: A

Rationale: Educating the patient on the importance of medication is crucial when dealing with a patient who is non-compliant with their hypertension medication. By providing information about the significance of the medication in controlling blood pressure and preventing complications, the patient may be more motivated to adhere to the prescribed treatment. Reassessing the patient in 6 months (choice B) may lead to further deterioration of the patient's condition if non-compliance continues. Referring the patient to a specialist (choice C) may be necessary in some cases but should be preceded by efforts to improve compliance. Discontinuing the medication (choice D) without addressing the non-compliance issue can have serious health consequences for the patient.

4. 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.

5. A client reports intimate partner violence to a nurse. What is the nurse's priority action?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Ensure the client has access to legal services.

Correct answer: A

Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.

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