Nursing Elites

1. The nurse is providing discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further teaching?

• A. I will avoid crossing my legs when sitting.
• B. I will use a raised toilet seat to prevent bending too far.
• C. I should keep my legs together to prevent dislocation.
• D. I will use a walker when moving around initially.

Correct answer: C

Rationale: The correct answer is C. Clients who have had a hip replacement should not keep their legs together to prevent dislocation. This position increases the risk of hip dislocation. Choices A, B, and D are correct statements. Avoiding crossing legs, using a raised toilet seat to prevent excessive bending, and using a walker when moving around initially are all appropriate measures to ensure proper recovery and prevent complications after a total hip replacement.

2. A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?

• A. Take phenytoin with antacids to reduce stomach upset.
• B. Maintain a consistent dosing schedule to prevent seizures.
• C. Monitor for excessive drowsiness and dizziness.
• D. Take the medication at bedtime to reduce seizure risk.

Correct answer: B

Rationale: The most important teaching the nurse should provide to a client prescribed phenytoin is to maintain a consistent dosing schedule to prevent seizures. Phenytoin is an antiepileptic drug, and missing doses can increase the risk of seizures. Option A is incorrect because antacids can interact with phenytoin and reduce its absorption. Option C is important but not the most critical teaching as compared to maintaining a consistent dosing schedule. Option D is incorrect because the timing of phenytoin administration should be consistent rather than specifically at bedtime.

3. A client with a colostomy is being discharged. What teaching is most important for the nurse to provide?

• A. Change the ostomy bag daily to prevent skin irritation.
• B. Avoid foods that can cause gas, such as broccoli.
• C. Empty the ostomy pouch when it is one-third full.
• D. Use a skin barrier to protect the surrounding skin.

Correct answer: C

Rationale: The most important teaching for a client with a colostomy is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining the proper seal of the pouching system. Changing the ostomy bag daily (Choice A) is not necessary unless it leaks or becomes loose. Avoiding gas-producing foods (Choice B) is essential for some clients but is not the most important teaching. Using a skin barrier (Choice D) is important but not as crucial as emptying the ostomy pouch at the right time to prevent complications.

4. The nurse is caring for a client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which intervention is most important for the nurse to implement?

• A. Encourage oral hydration
• B. Monitor for signs of dehydration
• C. Restrict fluid intake
• D. Administer IV fluids as prescribed

Correct answer: C

Rationale: In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia. The most crucial intervention is to restrict fluid intake to prevent further fluid overload and worsening of hyponatremia. Encouraging oral hydration (choice A) would exacerbate the condition by adding more fluids. Monitoring for signs of dehydration (choice B) is not appropriate as the client is at risk of fluid overload. Administering IV fluids (choice D) would worsen the hyponatremia and should be avoided.

5. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?

• A. Decreased heart rate
• B. Increased appetite
• C. Cold intolerance
• D. Weight gain

Correct answer: B

Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.

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