Nursing Elites

1. A client is postoperative following a hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to lie flat in bed.
• B. Apply heat to the incision site.
• C. Use an abduction pillow between the client's legs.
• D. Place a trochanter roll under the client's knees.

Correct answer: C

Rationale: Using an abduction pillow between the client's legs is essential in maintaining proper alignment and preventing dislocation of the hip joint following a hip arthroplasty. Encouraging the client to lie flat in bed (Choice A) is not recommended as early mobilization is crucial for preventing complications. Applying heat to the incision site (Choice B) is not typically done immediately postoperatively. Placing a trochanter roll under the client's knees (Choice D) is not as beneficial as using an abduction pillow to maintain proper positioning.

2. A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min
• B. Oxygen saturation of 95%
• C. Urine output of 30 mL/hr
• D. Serosanguineous wound drainage

Correct answer: C

Rationale: In a postoperative client, a urine output of 30 mL/hr is a concerning finding as it indicates oliguria, which may suggest dehydration or kidney impairment. Adequate urine output is essential for monitoring renal function and overall fluid status. A heart rate of 78/min is within the normal range for an adult. An oxygen saturation of 95% is acceptable and indicates adequate oxygenation. Serosanguineous wound drainage is expected in the early postoperative period and is not a cause for immediate concern unless it becomes excessive or changes character.

3. A nurse is planning to teach a group of clients about preventing low back pain. Which of the following information should the nurse include?

• A. Wear low-heeled shoes.
• B. Elevate the legs while sitting.
• C. Engage in prolonged sitting to rest the back muscles.
• D. Sleep on a soft mattress to prevent strain on the back.

Correct answer: A

Rationale: The correct answer is A: 'Wear low-heeled shoes.' Wearing low-heeled shoes helps prevent back strain by promoting proper posture. High heels can cause an imbalance in the body's alignment, leading to increased stress on the lower back. Choices B, C, and D are incorrect. Elevating the legs while sitting can help with circulation but does not directly prevent low back pain. Engaging in prolonged sitting can actually contribute to low back pain due to decreased muscle activity and increased pressure on the spine. Sleeping on a soft mattress may not provide adequate support for the back, potentially worsening back pain instead of preventing it.

4. Which electrolyte imbalance should be closely monitored in a patient receiving digoxin?

• A. Monitor potassium levels
• B. Monitor sodium levels
• C. Monitor calcium levels
• D. Monitor glucose levels

Correct answer: A

Rationale: Corrected Rationale: Potassium levels should be monitored closely in a patient receiving digoxin to avoid hypokalemia. Digoxin can increase the risk of developing life-threatening arrhythmias in the presence of low potassium levels. Monitoring sodium, calcium, or glucose levels is not specifically necessary for patients on digoxin, making choices B, C, and D incorrect.

5. A client who is at 36 weeks of gestation is scheduled for a nonstress test (NST). Which of the following statements by the client indicates an understanding of the teaching?

• A. I should fast for 12 hours before the test.
• B. I should expect the test to take about 10 minutes.
• C. I should have a full bladder for this test.
• D. I will need to have my blood glucose checked before the test.

Correct answer: B

Rationale: The correct answer is B. The nonstress test typically takes about 10 minutes and evaluates the fetal heart rate in response to fetal movement. Having a full bladder or fasting for 12 hours is not required for a nonstress test. Checking blood glucose levels is not part of the nonstress test procedure.

Similar Questions