Nursing Elites

1. Which activity is most important for a client recovering from a hip replacement to avoid during the first few weeks of recovery?

• A. Sitting in a chair for short periods
• B. Crossing the legs while sitting
• C. Walking with assistance
• D. Performing light stretching exercises

Correct answer: B

Rationale: The correct answer is B: Crossing the legs while sitting. Cross-leg position after a hip replacement can significantly increase the risk of hip dislocation. During the first few weeks of recovery, it is crucial for clients to avoid crossing their legs to protect the new joint. Choices A, C, and D are not as critical during the initial recovery phase. Sitting in a chair for short periods, walking with assistance, and performing light stretching exercises are generally encouraged activities that can help in the recovery process without posing a significant risk of complications like hip dislocation.

2. Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?

• A. Witness the consent and sign the form as a witness
• B. Inform the client of alternatives to the procedure
• C. Explain the procedure in detail to the client
• D. Determine that the surgical consent form has been signed and is included in the client's record

Correct answer: D

Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.

3. A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?

• A. Instruct the client to drink clear fluids and avoid solid foods.
• B. Administer antidiarrheal medication as prescribed.
• C. Encourage a high-fiber diet and regular physical activity.
• D. Restrict fluid intake and monitor electrolytes.

Correct answer: C

Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.

4. A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?

• A. Carrots
• B. White bread
• C. Bananas
• D. Apples

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.

5. A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. Which acid-base imbalance does the nurse anticipate the client developing?

• A. Metabolic alkalosis
• B. Respiratory alkalosis
• C. Respiratory acidosis
• D. Metabolic acidosis

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation from anxiety or fear causes an excessive loss of CO2, leading to respiratory alkalosis. This shift in pH results from the rapid, shallow breathing that reduces the level of carbon dioxide in the blood. Respiratory acidosis would occur in cases of poor ventilation or CO2 retention, while metabolic acidosis/alkalosis relates to disturbances in bicarbonate, not breathing patterns. Therefore, in this case, the client's hyperventilation due to anxiety would likely result in respiratory alkalosis, making option B the correct choice.

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