Nursing Elites

1. A nurse is caring for a client who is undergoing surgery for a hip fracture. What is a priority intervention to reduce the risk of postoperative complications?

• A. Encourage early ambulation
• B. Provide intravenous antibiotics
• C. Apply anti-embolism stockings
• D. Place a Foley catheter to monitor output

Correct answer: A

Rationale: Encouraging early ambulation is crucial in reducing the risk of postoperative complications, such as blood clots and pneumonia. Early mobilization helps prevent complications like deep vein thrombosis and pneumonia by promoting circulation and preventing respiratory complications. Providing intravenous antibiotics (Choice B) is important for preventing infections but is not the priority immediately post-surgery. Applying anti-embolism stockings (Choice C) is beneficial in preventing venous thromboembolism but does not address the immediate need for mobility. Placing a Foley catheter (Choice D) may be necessary during surgery but is not a priority intervention to reduce postoperative complications related to immobility.

2. A healthcare professional is reviewing the health history of a client who has a hip fracture. What is a risk factor for developing pressure injuries?

• A. Increased fluid intake
• B. Urinary incontinence
• C. Poor nutrition
• D. Immobility

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries as it can lead to skin breakdown due to constant exposure to moisture and irritation. Increased fluid intake is important for hydration and overall health but is not directly linked to pressure injuries. Poor nutrition can impair wound healing but is not a direct risk factor for pressure injuries. Immobility can contribute to the development of pressure injuries but is not as directly related as urinary incontinence.

3. A nurse is caring for a client who is postop following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?

• A. Increased fiber intake
• B. Decreased physical activity
• C. Frequent urge suppression
• D. Adequate sleep

Correct answer: B

Rationale: The correct answer is B: Decreased physical activity. Following abdominal surgery, reduced physical activity can contribute to constipation due to decreased bowel motility. Increased fiber intake (choice A) generally helps prevent constipation by adding bulk to the stool. Frequent urge suppression (choice C) may lead to issues like urinary retention but is not directly linked to constipation. Adequate sleep (choice D) is important for overall recovery but does not significantly impact constipation risk.

4. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

5. A client with diabetes mellitus is receiving discharge instructions about foot care from a nurse. Which statement indicates an understanding of the teaching?

• A. I will soak my feet in hot water daily
• B. I will wear shoes at all times
• C. I will cut my toenails in a rounded shape
• D. I will apply lotion between my toes after bathing

Correct answer: B

Rationale: The correct answer is B: 'I will wear shoes at all times.' This statement demonstrates an understanding of foot care for a client with diabetes. Wearing shoes at all times helps protect the feet, reducing the risk of injury and complications such as wounds or infections. Option A is incorrect because soaking feet in hot water can lead to skin dryness and increase the risk of burns or injury for individuals with diabetes. Option C is incorrect as cutting toenails in a rounded shape can cause ingrown toenails and potential infections. Option D is also incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

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