Nursing Elites

1. The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?

• A. Place an abduction pillow between the client's legs.
• B. Use an abduction pillow between the client's legs.
• C. Encourage the client to cross their legs while sitting.
• D. Encourage the client to sit upright for long periods.

Correct answer: B

Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.

2. The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?

• A. Encourage the client to ambulate
• B. Apply a warm compress to the left leg
• C. Elevate the client's left leg
• D. Administer a prescribed anticoagulant

Correct answer: C

Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.

3. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

• A. CAGE is a tool for general substance abuse screening.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response does not indicate alcohol addiction.
• D. All four responses must be positive to suggest alcohol dependence.

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

4. When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency?

• A. Reports of leg cramping at rest
• B. Family history of heart disease
• C. Current use of beta-blockers
• D. History of intermittent claudication

Correct answer: D

Rationale: Corrected Rationale: Intermittent claudication, or pain in the legs while walking that is relieved by rest, is a classic symptom of peripheral arterial insufficiency. Other factors such as a family history or medication use may contribute to cardiovascular health, but claudication is the most specific indicator. Leg cramping at rest is more indicative of conditions like peripheral neuropathy or deep vein thrombosis. Family history of heart disease and current use of beta-blockers are relevant to overall cardiovascular health, but they are not as directly related to chronic peripheral arterial insufficiency as intermittent claudication.

5. A client reports dizziness when standing up quickly. What advice should the nurse give?

• A. Encourage the client to drink more fluids.
• B. Change positions slowly to prevent dizziness.
• C. Report the symptom to the healthcare provider immediately.
• D. Limit physical activity to avoid triggering dizziness.

Correct answer: B

Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (Choice A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (Choice C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (Choice D) may not necessarily address the underlying cause of dizziness in this context.

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