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 caring for a client who is postoperative following an abdominal surgery. Which of the following assessments should the nurse prioritize?

• A. Assess the client's pain level.
• B. Monitor the client's respiratory rate.
• C. Measure the client's blood pressure.
• D. Check the client's bowel sounds.

Correct answer: B

Rationale: The correct answer is to monitor the client's respiratory rate. This assessment is crucial in the postoperative period to detect any respiratory complications such as hypoxia or respiratory distress. Assessing pain level (Choice A) is important but may not be the top priority as respiratory status takes precedence. Measuring blood pressure (Choice C) is also important but not as critical immediately postoperatively as monitoring respiratory function. Checking bowel sounds (Choice D) is relevant for assessing gastrointestinal function but is typically not the top priority in the immediate postoperative phase.

3. A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?

• A. Flush the tube with 30 mL of water every 4 hours.
• B. Position the client on the left side during feedings.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Check gastric residual every 2 hours.

Correct answer: C

Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.

4. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear cotton socks.
• C. Use a heating pad to warm your feet.
• D. Trim toenails straight across.

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

5. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include?

• A. Cleanse the wound with povidone-iodine.
• B. Apply a hydrocolloid dressing.
• C. Perform debridement as needed.
• D. Keep the wound open to air.

Correct answer: B

Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.

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