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 is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?

• A. Encourage the client to take deep breaths.
• B. Administer oxygen as needed.
• C. Teach the client pursed-lip breathing.
• D. Limit the client's fluid intake.

Correct answer: C

Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.

3. A nurse is teaching a newly licensed nurse about the stages of wound healing. The nurse should include in the teaching that collagen is added to the wound during which of the following stages?

• A. Hemostasis phase.
• B. Inflammatory phase.
• C. Proliferative phase.
• D. Maturation phase.

Correct answer: C

Rationale: The correct answer is C: Proliferative phase. During the proliferative phase of wound healing, collagen is added to the wound to promote tissue regeneration. In the hemostasis phase (choice A), the primary goal is to stop bleeding by forming a blood clot. The inflammatory phase (choice B) involves cleaning the wound and preparing it for healing. The maturation phase (choice D) is when the wound undergoes remodeling and gains strength, but collagen addition primarily occurs during the proliferative phase.

4. A nurse is caring for a client with deep vein thrombosis who is prescribed warfarin. Which of the following client statements indicates a need for further teaching?

• A. I will avoid vitamin K-rich foods.
• B. I will avoid using aspirin while on this medication.
• C. I will monitor my blood pressure regularly.
• D. I will increase my intake of leafy greens.

Correct answer: D

Rationale: The correct answer is D. Warfarin's effectiveness is reduced by high intake of vitamin K-rich foods, so increasing their intake would contradict the treatment plan. Choices A, B, and C are all appropriate statements for a client on warfarin therapy. Avoiding vitamin K-rich foods helps maintain the medication's effectiveness, avoiding aspirin reduces the risk of bleeding, and monitoring blood pressure is essential for overall health monitoring.

5. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent catheter-associated infections?

• A. Change the catheter every 24 hours
• B. Ensure the drainage bag is positioned above the bladder
• C. Perform routine irrigation of the catheter
• D. Empty the drainage bag every 4 hours

Correct answer: B

Rationale: The correct answer is to ensure the drainage bag is positioned above the bladder. This positioning prevents urine reflux into the bladder, reducing the risk of catheter-associated infections. Changing the catheter too frequently (Choice A) can actually increase the risk of infection by introducing pathogens. Performing routine catheter irrigation (Choice C) is no longer recommended as it can increase the risk of infection by introducing bacteria. Emptying the drainage bag every 4 hours (Choice D) is a standard practice to prevent urinary stasis but is not directly related to preventing catheter-associated infections.

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