Nursing Elites

1. The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

• A. Thick, tenacious pulmonary secretions
• B. Low-molecular-weight heparin doses
• C. SCDs wrapped around the legs
• D. Elastic stockings (TED hose)

Correct answer: B

Rationale: The correct answer is B, which is low-molecular-weight heparin doses. After hip replacement surgery, patients are at risk of developing deep vein thrombosis (DVT) due to immobility. Heparin and low-molecular-weight heparin are commonly used for prophylaxis against DVT. Monitoring for hemorrhage is crucial when administering anticoagulants. Choices A, C, and D are not directly related to monitoring for hemorrhage in this scenario. Thick, tenacious pulmonary secretions (Choice A) may indicate respiratory issues, SCDs (Choice C) help prevent DVT but do not directly relate to hemorrhage monitoring, and elastic stockings (TED hose) (Choice D) are used for DVT prophylaxis but do not alert to hemorrhage.

2. A nurse is planning care for a client who has a prescription for knee-length anti-embolic stockings. Which of the following actions should the nurse take?

• A. Remove the client’s stockings at least once during each shift
• B. Roll the top of the client’s stockings down to just below the knee
• C. Seat the client in a chair for 30 minutes prior to applying stockings
• D. Measure the length of the client’s leg from the heel to the gluteal fold

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the client’s stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client’s leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.

3. A healthcare provider is providing range of motion to the shoulder and must perform external rotation. Which action will the provider take?

• A. Moves the patient's arm in a full circle.
• B. Moves the patient's arm across the body as far as possible.
• C. Moves the patient's arm behind the body, keeping the elbow straight.
• D. Moves the patient's arm until the thumb is upward and lateral to the head with the elbow flexed.

Correct answer: D

Rationale: The correct action for external rotation of the shoulder involves moving the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position maximizes external rotation at the shoulder joint. Choices A, moving the arm in a full circle, B, moving the arm across the body, and C, moving the arm behind the body with the elbow straight, do not describe external rotation and are incorrect. Therefore, Choice D is the correct action for performing external rotation.

4. A client is being taught how to care for their tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

• A. Use tracheostomy covers when outdoors.
• B. Clean the tracheostomy site with hydrogen peroxide daily.
• C. Change the tracheostomy tube weekly.
• D. Apply ointment around the tracheostomy site.

Correct answer: A

Rationale: The correct instruction is to use tracheostomy covers when outdoors. Tracheostomy covers serve to protect the airway from environmental contaminants, reducing the risk of infection. Choice B is incorrect because hydrogen peroxide can be irritating to the skin and is not recommended for cleaning the tracheostomy site. Choice C is incorrect as tracheostomy tubes should not be routinely changed weekly unless there is a specific medical indication. Changing it without a need can introduce infection or damage the stoma. Choice D is incorrect as applying ointment around the tracheostomy site can lead to occlusion of the stoma and interfere with breathing.

5. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?

• A. 'All of this equipment can be frightening.'
• B. 'The equipment is necessary to monitor your condition.'
• C. 'You should try to ignore the equipment.'
• D. 'Try to relax; the equipment is not harmful.'

Correct answer: A

Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.

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