Nursing Elites

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

• A. I will avoid sitting in a chair for longer than 30 minutes.
• B. I will avoid crossing my legs when sitting.
• C. I will bend at the hips to pick up items from the floor.
• D. I will avoid using a raised toilet seat.

Correct answer: C

Rationale: The correct answer is C because bending at the hips can dislocate the hip joint in clients who have had a total hip arthroplasty. This movement should be avoided to prevent complications post-surgery. Choices A, B, and D are all correct statements for a client who has had a total hip arthroplasty. Avoiding prolonged sitting, crossing legs, and using a raised toilet seat are all appropriate measures to ensure proper healing and prevent complications.

2. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. The client reports pain of 8 on a scale of 0 to 10. Which of the following actions should the nurse take?

• A. Administer ibuprofen 400 mg PO
• B. Administer oxycodone 10 mg PO
• C. Reposition the client to the unaffected side
• D. Apply a cold compress to the affected knee

Correct answer: B

Rationale: In this scenario, the appropriate action for the nurse to take when a client reports severe postoperative pain of 8 out of 10 is to administer oxycodone 10 mg PO. Oxycodone is a potent analgesic that is more effective in managing severe pain compared to ibuprofen, making choice A incorrect. Repositioning the client to the unaffected side or applying a cold compress may provide some comfort but are not the priority interventions for severe postoperative pain, making choices C and D less appropriate.

3. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of water after feeding
• B. Flush the tube with 10 mL of sterile water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.

4. A nurse is assessing a client who is experiencing a panic attack. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Chest pain.
• D. Dilated pupils.

Correct answer: D

Rationale: During a panic attack, the sympathetic nervous system is activated, leading to physiological responses such as dilated pupils. Bradycardia (slow heart rate) and hypotension (low blood pressure) are not typically associated with panic attacks. While chest pain can occur during a panic attack due to rapid breathing and muscle tension, dilated pupils are a more specific finding related to sympathetic activation in this context.

5. What is the first intervention when a patient has difficulty breathing post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Check oxygen saturation
• D. Elevate the head of the bed

Correct answer: A

Rationale: Administering oxygen is the initial intervention for a patient experiencing breathing difficulties post-surgery. Providing oxygen helps improve oxygenation and alleviate respiratory distress. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in addressing hypoxia and respiratory compromise.

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