Nursing Elites

1. A patient is 1 day postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

• A. Administer aspirin for pain management.
• B. Keep the affected leg in a dependent position.
• C. Flex the affected knee for 2 to 3 minutes every hour.
• D. Apply ice packs to the affected knee.

Correct answer: D

Rationale: The correct action for a client 1 day postoperative following a total knee arthroplasty is to apply ice packs to the affected knee. Ice packs help reduce swelling and pain in such clients. Administering aspirin is contraindicated due to the risk of bleeding postoperatively. Keeping the affected leg in a dependent position can impair circulation and increase the risk of complications. Flexing the affected knee for extended periods can strain the surgical site and hinder the healing process.

2. A nurse is assessing a client who is in active labor, and the FHR baseline has been 100/min for 15 minutes. What should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: The correct answer is C: Maternal hypoglycemia. Maternal hypoglycemia can lead to fetal bradycardia, which is indicated by a baseline FHR of 100/min. In this scenario, the sustained low baseline FHR suggests a possible link to maternal hypoglycemia. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) usually causes fetal tachycardia as a compensatory mechanism to deliver more oxygen to tissues. Chorioamnionitis (Choice D) is associated with maternal fever and an elevated fetal heart rate, not a sustained low baseline FHR.

3. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head uncovered.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.

4. A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?

• A. Shave the hair at the insertion site.
• B. Cleanse the site with povidone-iodine.
• C. Wear sterile gloves when changing the dressing.
• D. Change the IV site every 48 to 72 hours.

Correct answer: D

Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.

5. A client who is at 30 weeks of gestation and is scheduled for a nonstress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should avoid drinking fluids during the test.
• B. I will need to drink a sugar solution before the test.
• C. This test will monitor how my baby is responding to contractions.
• D. This test will assess for fetal lung maturity.

Correct answer: B

Rationale: The correct answer is B because the client should drink a sugar solution for a glucose challenge test, which is part of the nonstress test protocol during pregnancy. Choice A is incorrect because adequate hydration is generally recommended before the test. Choice C is incorrect as the nonstress test monitors the baby's heart rate in response to its own movements, not contractions. Choice D is incorrect as the nonstress test does not assess fetal lung maturity.

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