Nursing Elites

1. The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?

• A. Assist the client to a sitting position at the edge of the bed
• B. Have the client march in place for 30 seconds
• C. Have the client raise his arms above his head
• D. Ask the client the last time he fell

Correct answer: A

Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.

2. Teaching about the importance of avoiding foods high in potassium is most crucial for which client?

• A. a client receiving diuretic therapy
• B. a client with an ileostomy
• C. a client with metabolic alkalosis
• D. a client with renal disease

Correct answer: D

Rationale: Clients with renal disease are prone to hyperkalemia due to impaired kidney function, making it crucial for them to avoid foods high in potassium to prevent further complications. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk of hypokalemia. These individuals should actually consume foods high in potassium to replenish the electrolyte lost through diuresis, ileostomy output, or metabolic alkalosis.

3. The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound, what will the nurse use?

• A. Sterile saline
• B. Distilled water
• C. Betadine scrub
• D. Tap water

Correct answer: A

Rationale: When irrigating a wound, especially in the case of a full-thickness burn, it is crucial to use a solution that is gentle and non-irritating to the tissues. Sterile saline is the preferred choice for wound irrigation as it is isotonic and does not cause additional damage to the already compromised tissue. Distilled water lacks the electrolytes present in saline, Betadine scrub is not used for irrigation due to its potential to be cytotoxic, and tap water may introduce contaminants and microorganisms to the wound.

4. How can a diet high in fiber content benefit an individual?

• A. aid in rapid weight loss.
• B. reduce diabetic ketoacidosis.
• C. lower cholesterol.
• D. reduce the requirement for folate.

Correct answer: C

Rationale: A diet high in fiber content can help lower cholesterol levels. Fiber-rich foods such as grains, apples, potatoes, and beans are known to aid in reducing cholesterol by binding to cholesterol in the digestive system and preventing its absorption into the bloodstream. Choice A is incorrect as the question does not specify losing weight rapidly but rather focuses on the benefits of a high-fiber diet, which includes aiding in weight management through promoting satiety and regulating digestion. Choice B is incorrect because while fiber helps manage blood sugar levels, it is not directly related to reducing diabetic ketoacidosis, a serious complication of diabetes. Choice D is incorrect as a high-fiber diet does not reduce the need for folate; however, it can aid in the absorption of folate and other essential nutrients.

5. A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, 'I need this surgery because nothing else I have done has helped me to lose weight.' Which response by the nurse is most appropriate?

• A. "If you eat less, you can save some money."?
• B. "Exercise is a healthier way to lose weight."?
• C. "You should try the Atkins diet first."?
• D. "I respect your decision to choose surgery."?

Correct answer: D

Rationale: The most appropriate response by the nurse is to show respect and empathy towards the client's decision. Choosing surgery for weight loss is a significant decision, and acknowledging and respecting this choice is crucial in providing patient-centered care. Option D is the correct answer as it validates the client's decision and shows support. Options A, B, and C are all inappropriate as they do not address the client's feelings, lack empathy, and can be considered insensitive and unprofessional.

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