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 urinary tract infection (UTI) is prescribed antibiotics. What is the most important instruction for the nurse to give the client?

• A. Take the antibiotics with food
• B. Complete the full course of antibiotics
• C. Increase fluid intake to at least 2 liters per day
• D. Take over-the-counter pain relievers for discomfort

Correct answer: B

Rationale: The most crucial instruction for the nurse to give a client with a UTI who is prescribed antibiotics is to complete the full course of antibiotics. Completing the full course of antibiotics is essential to ensure that the infection is fully treated and to prevent the development of antibiotic resistance. While taking antibiotics with food, increasing fluid intake, and managing discomfort with pain relievers are important aspects of UTI management, completing the prescribed course of antibiotics is the top priority to achieve the best treatment outcomes and prevent recurrence of the infection.

3. A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?

• A. Auscultate breath sounds.
• B. Measure vital signs.
• C. Palpate the abdomen.
• D. Observe the skin for bruising.

Correct answer: C

Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.

4. A client's chest tube insertion site has crepitus (crackling sensation) upon palpation. What is the nurse's next step?

• A. Apply a pressure dressing to the chest tube site.
• B. Administer an oral antihistamine.
• C. Assess the client for allergies to cleaning agents.
• D. Measure the area of swelling and crackling.

Correct answer: D

Rationale: The correct next step for the nurse is to measure the area of crepitus. Crepitus indicates subcutaneous emphysema, which is a serious condition requiring monitoring. Applying a pressure dressing (Choice A) could worsen the condition by trapping air under the skin. Administering an oral antihistamine (Choice B) is not indicated for crepitus. Assessing for allergies to cleaning agents (Choice C) is not the priority when dealing with crepitus and subcutaneous emphysema.

5. A nurse receives a report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reported that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first?

• A. Measure urinary output
• B. Assess for weakness or dizziness
• C. Increase IV fluids
• D. Check for vaginal bleeding

Correct answer: D

Rationale: Saturation of the perineal pad after a hysterectomy suggests excessive vaginal bleeding, which must be addressed immediately. Assessing for vaginal bleeding is the priority in this situation as it can lead to hypovolemic shock. Measuring urinary output, assessing for weakness or dizziness, and increasing IV fluids are important interventions but checking for vaginal bleeding takes precedence due to the risk of hemorrhage post-hysterectomy.

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