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 client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?

• A. Apply the stockings with the creases on the front of the leg.
• B. Apply the stockings while the client's legs are in a dependent position.
• C. Remove the stockings at least once per shift.
• D. Remove the stockings while the client is sitting in a reclining chair.

Correct answer: C

Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.

3. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

• A. Compare prescriptions with medications the client received during hospitalization.
• B. Only review the client’s current medications.
• C. Provide a list of medications without checking for interactions.
• D. Discuss the client’s medication history without verification.

Correct answer: A

Rationale: The correct answer is A: Compare prescriptions with medications the client received during hospitalization. This step is crucial in ensuring the accuracy of medication reconciliation. By comparing the current prescriptions with the medications administered during the hospital stay, the nurse can identify any discrepancies, omissions, or duplications in the medications. This comprehensive comparison helps prevent medication errors and ensures that the client's home medications align with the treatment received in the hospital. Choice B is incorrect because solely reviewing the client's current medications may overlook important changes or additions made during the hospitalization. Choice C is incorrect as providing a list of medications without checking for interactions can lead to potential adverse effects or drug interactions. Choice D is incorrect as discussing the client's medication history without verification may not provide an accurate representation of the medications the client actually received during the hospital stay.

4. While auscultating a client's abdomen, a nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following?

• A. Gallop
• B. Bruit
• C. Thrill
• D. Murmur

Correct answer: B

Rationale: The correct answer is B: Bruit. A bruit is a blowing sound indicating turbulent blood flow, often heard over the aorta. Choices A, C, and D are incorrect. A gallop is a cardiac sound resembling the sound of a galloping horse. A thrill is a vibration felt on palpation, and a murmur is a swooshing or whooshing sound heard during auscultation of the heart or blood vessels. In this scenario, the blowing sound over the aorta specifically indicates a bruit, which signifies turbulent blood flow and should be further assessed by the healthcare provider.

5. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

• A. Help the client write down the questions to ask the provider, so that the client doesn’t forget
• B. Reassure the client that everything will be explained
• C. Explain the procedure in detail yourself
• D. Direct the client to search for information online

Correct answer: A

Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.

Similar Questions