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 has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take?

• A. Alert the American Nurses Association.
• B. Fill out an incident report.
• C. Report the observations to the nurse manager on the unit.
• D. Leave the nurse alone to sleep.

Correct answer: C

Rationale: Reporting the observations to the nurse manager is the appropriate action to ensure the safety of the clients and address potential impairment. The nurse manager can take necessary steps to assess the situation and intervene if needed. Alerting the American Nurses Association (Choice A) is not necessary at this stage as the immediate concern is the safety of clients in the unit. Filling out an incident report (Choice B) may be required later, but the priority is to address the issue promptly by involving the immediate supervisor. Leaving the nurse alone to sleep (Choice D) is not a safe option as it does not address the underlying problem of potential impairment and safety concerns; it is essential to address the issue promptly to ensure patient safety.

3. A client appears upset about the IV catheter insertion but does not communicate it to the nurse after being informed about the prescribed IV fluids. Which of the following is an appropriate nursing response?

• A. Ignore the client’s discomfort
• B. Reassure the client without addressing concerns
• C. Is there something about this procedure that concerns you?
• D. Proceed with the procedure

Correct answer: C

Rationale: The appropriate nursing response in this situation is to ask the client if there are any concerns about the procedure. By doing so, the nurse acknowledges the client's distress and opens up a dialogue to address any anxieties or misconceptions. Option A is incorrect as ignoring the client’s discomfort can lead to increased anxiety and potential harm. Option B is not ideal as reassuring the client without addressing specific concerns may not alleviate the client's distress. Option D is incorrect because proceeding with the procedure without addressing the client's unspoken concerns can further escalate the client's distress.

4. A healthcare professional is providing teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the professional include?

• A. Urticaria
• B. Ptosis
• C. Nausea
• D. Hematuria

Correct answer: A

Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. It presents as raised, red, itchy welts on the skin. Ptosis is drooping of the upper eyelid and is not typically associated with allergic reactions. Nausea is a gastrointestinal symptom that can occur with various conditions but is not specific to allergic reactions. Hematuria, which is the presence of blood in the urine, is not a typical manifestation of an allergic reaction.

5. The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?

• A. Providing nail care
• B. Teaching foot care
• C. Making the patient's bed
• D. Determining aspiration risk

Correct answer: C

Rationale: The correct answer is making the patient's bed. Delegating bed-making tasks to nursing assistive personnel is appropriate as it falls within their scope of practice and helps free up the nurse's time to focus on tasks that require their specialized skills and knowledge. Providing nail care and teaching foot care involve direct patient care and education, which should be performed by licensed nursing staff. Determining aspiration risk requires critical thinking and clinical judgment, making it a responsibility of the nurse.

Similar Questions