Nursing Elites

1. A patient is 1 day postoperative following a hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the hip?

• A. Keep the patient in a side-lying position.
• B. Place a pillow between the patient's legs.
• C. Instruct the patient to avoid sitting for long periods.
• D. Elevate the head of the bed to 90 degrees.

Correct answer: B

Rationale: Placing a pillow between the patient's legs is the correct action to prevent dislocation of the hip following arthroplasty. This technique helps maintain proper alignment and stability of the hip joint. Keeping the patient in a side-lying position may not provide the necessary support to prevent hip dislocation. Instructing the patient to avoid sitting for long periods is important for preventing complications like deep vein thrombosis but does not directly prevent hip dislocation. Elevating the head of the bed to 90 degrees is not relevant to preventing hip dislocation in a postoperative hip arthroplasty patient.

2. A nurse is assessing a client who is 1 day postoperative following hip replacement surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Serosanguineous drainage on the surgical dressing
• C. Blood pressure of 118/76 mm Hg
• D. Urine output of 40 mL/hr

Correct answer: D

Rationale: The correct answer is D: Urine output of 40 mL/hr. A low urine output may indicate kidney complications, such as acute kidney injury, which is a critical finding postoperatively. The nurse should report this immediately to the provider for further evaluation and management. Choices A, B, and C are within normal limits for a client who is 1 day postoperative following hip replacement surgery and do not indicate immediate concerns that require reporting to the provider.

3. A nurse is providing dietary teaching to a client who has a new diagnosis of hypertension. Which of the following foods should the nurse instruct the client to avoid?

• A. Canned soup.
• B. Lean cuts of beef.
• C. Bananas.
• D. Baked chicken.

Correct answer: A

Rationale: The correct answer is A: Canned soup. Canned soups are usually high in sodium, which can increase blood pressure and should be avoided by clients with hypertension. Lean cuts of beef, bananas, and baked chicken are healthier options for individuals with hypertension as they are lower in sodium and can be included in a balanced diet to manage blood pressure levels.

4. A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of the following actions should the nurse take?

• A. Allow the child to handle the IV supplies to become familiar with them.
• B. Tell the child they will feel discomfort during the catheter insertion.
• C. Use a mummy restraint to hold the child during the catheter insertion.
• D. Require the parents to leave the room during the procedure.

Correct answer: B

Rationale: The correct answer is B because informing the child that they will feel discomfort during catheter insertion is crucial to prepare them for the procedure. Choice A is incorrect as children should not handle medical supplies. Choice C is inappropriate as using a restraint can cause anxiety and fear in the child. Choice D is not necessary as having parents present can provide comfort and support to the child during the procedure.

5. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the healthcare professional take first?

• A. Check the residual volume.
• B. Flush the tube with 0.9% sodium chloride.
• C. Elevate the head of the bed to 45 degrees.
• D. Warm the formula to body temperature.

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees is the priority action before administering an enteral feeding through an NG tube. This position helps prevent aspiration by promoting proper flow and digestion of the feeding. Checking the residual volume, flushing the tube, and warming the formula are important steps but come after ensuring the client is in the correct position to minimize the risk of complications.

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