Nursing Elites

1. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

• A. Place a pillow under the client's knees
• B. Keep the client's legs elevated
• C. Flex the client's knee every 2 hours
• D. Apply heat to the operative knee

Correct answer: B

Rationale: Keeping the client's legs elevated is the appropriate action to prevent venous thromboembolism following a total knee arthroplasty. Elevating the legs helps promote circulation and reduce the risk of blood clots. Placing a pillow under the client's knees may provide comfort but does not address the specific postoperative complication. Flexing the client's knee every 2 hours may be contraindicated as excessive movement can disrupt the surgical site. Applying heat to the operative knee is not recommended immediately postoperatively as it can increase swelling and discomfort.

2. A nurse in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

• A. Obtain a baseline ECG
• B. Obtain a blood specimen for ABG analysis
• C. Insert an 18-gauge IV catheter
• D. Administer 100% humidified oxygen

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.

3. What is the recommended dietary restriction for a patient with chronic kidney disease?

• A. Limit potassium intake
• B. Limit fluid intake
• C. Increase protein intake
• D. Increase carbohydrate intake

Correct answer: B

Rationale: The correct answer is to limit fluid intake for a patient with chronic kidney disease. This restriction helps manage fluid balance to prevent fluid overload. Choices A, C, and D are incorrect. Limiting potassium intake is essential for some patients with kidney disease, but it is not the primary dietary restriction. Increasing protein intake is usually not recommended due to the impaired kidney function in these patients. Increasing carbohydrate intake is also not a standard recommendation for patients with chronic kidney disease.

4. A client has a nasogastric tube and is receiving intermittent enteral feedings. Which of the following actions should the nurse take to prevent aspiration?

• A. Administer a bolus feeding over 10 minutes.
• B. Elevate the head of the bed to 45 degrees during feedings.
• C. Flush the tube with 10 mL of sterile water before feedings.
• D. Position the client on the left side during feedings.

Correct answer: B

Rationale: To prevent aspiration in clients with a nasogastric tube receiving intermittent enteral feedings, the nurse should elevate the head of the bed to 45 degrees during feedings. This position helps reduce the risk of regurgitation and aspiration of the feeding contents. Administering a bolus feeding over 10 minutes (choice A) may not prevent aspiration as effectively as elevating the head of the bed. Flushing the tube with sterile water before feedings (choice C) is important for tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (choice D) is not the recommended action to prevent aspiration; elevating the head of the bed is more effective.

5. A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of furosemide. Which of the following findings indicates the nurse should increase the client's infusion rate?

• A. Urine output of 20 mL/hr
• B. Heart rate of 90/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1 kg in 24 hr

Correct answer: D

Rationale: A weight gain of 1 kg in 24 hours can indicate fluid retention and worsening heart failure, requiring an increase in diuresis. This finding suggests that the current diuretic therapy is not effective enough to manage the fluid overload, necessitating an increase in the infusion rate of furosemide. Choices A, B, and C are not directly related to the need for an increase in diuretic therapy in heart failure patients. Urine output of 20 mL/hr, a heart rate of 90/min, and a sodium level of 138 mEq/L are important parameters to monitor but do not specifically indicate the need to increase the infusion rate of furosemide.

Similar Questions