Nursing Elites

1. A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?

• A. Instruct the client to perform ankle pumps
• B. Administer anticoagulant therapy as prescribed
• C. Maintain the client in a prone position
• D. Encourage the client to ambulate as tolerated

Correct answer: B

Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.

2. A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

• A. Pressured speech
• B. Increased appetite
• C. Lack of sleep
• D. Mood swings

Correct answer: C

Rationale: The correct answer is C: 'Lack of sleep.' In a client experiencing acute mania due to bipolar disorder, lack of sleep is the priority finding for the nurse to address. Sleep deprivation can exacerbate symptoms, lead to exhaustion, and increase the risk of further complications. Pressured speech, increased appetite, and mood swings are also common in acute mania, but addressing the lack of sleep takes precedence due to its significant impact on the client's well-being and recovery.

3. A client with a tracheostomy is exhibiting signs of respiratory distress. What is the nurse's immediate priority?

• A. Increase the oxygen flow rate
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Administer a bronchodilator

Correct answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the immediate priority for the nurse is to suction the tracheostomy. This action helps clear the airway of secretions and ensures that the client can breathe effectively. Increasing the oxygen flow rate may be necessary but addressing the airway obstruction is more critical. Notifying the physician immediately is important but may cause a delay in addressing the immediate need for airway clearance. Administering a bronchodilator may help with bronchospasm but should not take precedence over ensuring a clear airway in a client with respiratory distress.

4. Which dietary restriction should be taught to a client with chronic kidney disease?

• A. Increase potassium-rich foods
• B. Limit phosphorus and potassium intake
• C. Encourage increased protein intake
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Limit phosphorus and potassium intake. In chronic kidney disease, the kidneys are unable to effectively filter these minerals from the blood, leading to their accumulation and potential complications. Restricting phosphorus and potassium intake is crucial in managing the progression of the disease. Choice A is incorrect as increasing potassium-rich foods can worsen the condition. Choice C is also incorrect as excessive protein intake can put more strain on the kidneys. Choice D is not the priority; rather, fluid intake should be monitored based on individual needs and stage of kidney disease.

5. A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following interventions should the nurse take?

• A. Assess for bladder distention after 6 hours
• B. Encourage the client to use a bedpan in the supine position
• C. Restrict the client's intake of oral fluids
• D. Pour warm water over the client's perineum

Correct answer: D

Rationale: The correct answer is to pour warm water over the client's perineum. This intervention can help stimulate voiding after catheter removal by promoting relaxation of the perineal muscles and increasing sensory input to the bladder. Assessing for bladder distention after 6 hours (Choice A) is important but not the initial intervention for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not be effective in promoting voiding. Restricting the client's intake of oral fluids (Choice C) is not appropriate as hydration is important for urinary function.

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