Nursing Elites

1. The nurse is caring for a client who underwent a total knee replacement yesterday. What activity level should the nurse encourage today?

• A. Bed rest with bathroom privileges only
• B. Frequent, short walks with assistance
• C. Range of motion exercises to the knee every four hours
• D. Leg elevation to reduce swelling

Correct answer: B

Rationale: After a total knee replacement, early ambulation is crucial for promoting circulation and preventing complications like thrombosis. Bed rest should be avoided as it can increase the risk of complications. Range of motion exercises are important but should be performed gradually and not excessively. Leg elevation is beneficial for reducing swelling but should not be the primary activity level encouraged immediately after surgery.

2. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?

• A. Administer oxygen as prescribed
• B. Perform an ECG
• C. Obtain a detailed health history
• D. Monitor vital signs regularly

Correct answer: B

Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.

3. The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?

• A. Bilateral leg swelling.
• B. Sudden onset of chest pain.
• C. Gradual onset of dyspnea.
• D. Decreased breath sounds on auscultation.

Correct answer: C

Rationale: The correct answer is C: 'Gradual onset of dyspnea.' While pulmonary embolism can present with various symptoms, the most common include sudden onset of dyspnea, chest pain (often pleuritic in nature), tachypnea, and tachycardia. Bilateral leg swelling is more commonly associated with conditions like deep vein thrombosis, not pulmonary embolism. Decreased breath sounds on auscultation may be seen in conditions like pneumothorax, not typically in pulmonary embolism. Therefore, the gradual onset of dyspnea is the most indicative symptom of pulmonary embolism in this scenario.

4. Before administration of a stat dose of potassium chloride IV for a client with hypokalemia, what is the most important action for the nurse?

• A. Ensure the IV is flowing freely
• B. Mix the medication thoroughly
• C. Check the client’s electrolyte levels
• D. Obtain a baseline ECG

Correct answer: A

Rationale: The most crucial action for the nurse before administering a stat dose of potassium chloride IV to a client with hypokalemia is to ensure the IV is flowing freely. A freely flowing IV is essential to safely and effectively deliver potassium chloride, helping to prevent infusion-related issues. Checking the client's electrolyte levels or obtaining a baseline ECG may be important but are not the most critical actions before administering the medication. Mixing the medication thoroughly is not applicable in this scenario as potassium chloride is typically provided ready to use.

5. The nurse is providing discharge instructions to a client with a diagnosis of peptic ulcer disease (PUD). Which dietary recommendation is most appropriate?

• A. Increase fiber intake.
• B. Avoid spicy foods.
• C. Avoid dairy products.
• D. Consume a high-fat diet.

Correct answer: B

Rationale: The most appropriate dietary recommendation for a client with peptic ulcer disease (PUD) is to avoid spicy foods. Spicy foods can irritate the stomach lining and exacerbate symptoms of PUD. Increasing fiber intake may be beneficial for other gastrointestinal conditions but is not the primary concern for PUD. Avoiding dairy products is not a general recommendation for PUD unless the individual has a specific intolerance. Consuming a high-fat diet can increase the risk of exacerbating PUD symptoms due to the delayed gastric emptying associated with high-fat meals.

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