Nursing Elites

1. A healthcare professional is assessing a client who has a hip fracture. Which of the following findings should the healthcare professional expect?

• A. Hip pallor
• B. Leg abduction
• C. Muscle spasms
• D. Leg lengthening

Correct answer: C

Rationale: Muscle spasms are a common finding in clients with hip fractures. The muscle spasms occur due to the body's natural response to the injury, causing involuntary contractions. Hip pallor (Choice A) is not typically associated with hip fractures. Leg abduction (Choice B) and leg lengthening (Choice D) are not typical findings in clients with hip fractures, as the fracture usually results in limited range of motion and shortening of the affected limb.

2. What are the important considerations when administering blood products to a patient?

• A. Ensuring proper documentation of the transfusion
• B. Verifying the patient's identity before administration
• C. Monitoring for allergic reactions or transfusion reactions
• D. Monitoring the patient's vital signs during transfusion

Correct answer: B

Rationale: Verifying the patient's identity before administration is a critical step to ensure that the correct blood product is given to the right patient, thereby preventing transfusion errors. While ensuring proper documentation of the transfusion (choice A) is important for record-keeping, verifying patient identity (choice B) directly addresses the risk of administering blood to the wrong patient. Monitoring for allergic reactions or transfusion reactions (choice C) and monitoring the patient's vital signs during transfusion (choice D) are also essential considerations during blood product administration, but verifying patient identity takes precedence to prevent potentially life-threatening errors.

3. A client who had a stroke is complaining of left-side weakness. What should the nurse prioritize?

• A. Initiate physical therapy immediately.
• B. Contact the physical therapy team.
• C. Reassess the client after administering pain medication.
• D. Start treatment immediately without consulting anyone.

Correct answer: B

Rationale: The correct answer is to contact the physical therapy team. When a client who had a stroke presents with left-side weakness, the nurse should prioritize coordinating with the physical therapy team rather than immediately initiating physical therapy. The initial step should involve assessing the client's condition and involving the appropriate healthcare team for a comprehensive care plan. Administering pain medication or starting treatment without consulting others can delay or hinder the appropriate care needed for the client's recovery.

4. A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?

• A. Urinary output
• B. Pain level
• C. Oxygen saturation
• D. Abdominal dressing

Correct answer: C

Rationale: The correct answer is C: Oxygen saturation. Following abdominal surgery, the priority assessment is to ensure adequate oxygenation. Monitoring oxygen saturation is crucial as the client may be at risk of respiratory complications due to the effects of anesthesia, pain medications, and the surgical procedure itself. Assessing urinary output is important for monitoring kidney function but is not the priority immediately postoperatively. Pain level assessment is essential for the client's comfort but does not take precedence over ensuring oxygen saturation. Checking the abdominal dressing is important for wound assessment, but ensuring adequate oxygenation is the priority in the immediate postoperative period.

5. A client with renal calculi is admitted. What is the priority nursing intervention?

• A. Monitor urinary output every shift.
• B. Administer pain medication as ordered.
• C. Strain all urine for stones.
• D. Increase fluid intake to flush the urinary tract.

Correct answer: C

Rationale: The correct answer is to strain all urine for stones. This is the priority nursing intervention for a client with renal calculi as it helps in identifying and preventing stones from passing unnoticed. Monitoring urinary output, administering pain medication, and increasing fluid intake are important aspects of care for this client, but the priority is to ensure that any passed stones are collected and analyzed to guide further treatment.

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