Nursing Elites

1. What does the nurse's signature on the client’s surgical consent form signify?

• A. The client voluntarily grants permission for the procedure to be done
• B. The client is competent to sign the consent without impairment of judgment
• C. The client understands the risks and benefits associated with the procedure
• D. The client has signed the form freely and voluntarily

Correct answer: A

Rationale: The nurse's signature on a surgical consent form signifies that the client voluntarily grants permission for the procedure to be done. This is the correct answer because the nurse's signature does not imply the client's competence, understanding of risks and benefits, or that the client signed the form freely and voluntarily. The nurse's role is to verify that the client has made an informed decision and is providing consent for the procedure.

2. The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?

• A. Place an abduction pillow between the client's legs.
• B. Use an abduction pillow between the client's legs.
• C. Encourage the client to cross their legs while sitting.
• D. Encourage the client to sit upright for long periods.

Correct answer: B

Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.

3. A client with hyperkalemia is receiving insulin and glucose. Which laboratory value should the nurse monitor closely?

• A. Monitor the client's blood glucose level.
• B. Monitor the client's sodium level.
• C. Monitor the client's calcium level.
• D. Monitor the client's potassium level.

Correct answer: D

Rationale: The correct answer is to monitor the client's potassium level. When administering insulin and glucose in hyperkalemia, the aim is to shift potassium from the bloodstream into the cells, lowering elevated levels. Therefore, monitoring potassium levels closely is essential to prevent hypokalemia or further complications. Monitoring blood glucose levels (Choice A) is important but not the priority in this scenario. Monitoring sodium (Choice B) and calcium levels (Choice C) is not directly related to the treatment of hyperkalemia with insulin and glucose.

4. A client with cirrhosis and ascites asks about fluid restriction. What is the nurse’s best response?

• A. Increase the client's fluid intake gradually.
• B. Restrict oral fluids to 1500 ml per day.
• C. Explain the importance of following a low-sodium diet.
• D. Increase dietary protein to reduce fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Restrict oral fluids to 1500 ml per day.' In clients with cirrhosis and ascites, fluid restriction is essential to prevent fluid overload, which can worsen symptoms of liver failure. Option A is incorrect because increasing fluid intake would exacerbate the issue of fluid overload. Option C, while important, is not the best initial response to the client's question about fluid restriction. Option D is incorrect as increasing dietary protein does not directly address fluid restriction in clients with cirrhosis and ascites.

5. A young adult was hit in the temporal area with a baseball bat and is being monitored for signs of a closed head injury. Which finding indicates a developing epidural hematoma?

• A. Nausea and vomiting.
• B. Altered consciousness within the first 24 hours after injury.
• C. Severe headache and blurred vision.
• D. Loss of motor function on the affected side.

Correct answer: B

Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.

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