Nursing Elites

1. A nurse is planning care for a client who is 1 day postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include?

• A. Keep the affected leg elevated as needed.
• B. Apply ice packs to the affected knee as prescribed.
• C. Encourage the client to ambulate as soon as possible.
• D. Perform range-of-motion exercises as instructed.

Correct answer: C

Rationale: Encouraging the client to ambulate as soon as possible is essential in preventing complications like deep vein thrombosis post knee arthroplasty. While keeping the affected leg elevated and applying ice packs can be beneficial in certain situations, early ambulation takes precedence in this case. Performing range-of-motion exercises hourly may not be necessary and could potentially cause more harm than good if not done correctly or excessively.

2. A nurse is assessing a client who has hypovolemia. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Tachycardia.
• C. Increased blood pressure.
• D. Bounding pulse.

Correct answer: B

Rationale: The correct answer is B: Tachycardia. In hypovolemia, the body responds to decreased fluid volume by increasing the heart rate (tachycardia) to maintain adequate circulation. Bradycardia (Choice A) is not expected in hypovolemia since the heart rate typically increases to compensate for the reduced blood volume. Increased blood pressure (Choice C) is unlikely in hypovolemia as the decreased fluid volume leads to decreased pressure. A bounding pulse (Choice D) is more associated with conditions like hyperthyroidism or fever, not specifically with hypovolemia.

3. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?

• A. Placing a belt restraint on a school-age child who has seizures.
• B. Securing wrist restraints to the bed rails for an adolescent.
• C. Applying elbow immobilizers to an infant receiving cleft lip injury.
• D. Keeping the side rails of a toddler's crib elevated.

Correct answer: D

Rationale: The correct answer is D. Keeping the side rails of a toddler's crib elevated is an appropriate use of restraints to prevent the child from falling, which is an essential safety measure. Placing a belt restraint on a school-age child with seizures (choice A) is not recommended as it can be dangerous during a seizure. Securing wrist restraints to the bed rails for an adolescent (choice B) may cause harm and should not be done routinely. Applying elbow immobilizers to an infant receiving a cleft lip injury (choice C) is not a standard practice for managing this condition and would not be appropriate.

4. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

• A. Store the glasses in a labeled case
• B. Clean the glasses with hot water
• C. Clean the glasses with a paper towel
• D. Store the glasses on the bedside table

Correct answer: A

Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This ensures the safety of the glasses and helps in their proper identification when needed. Cleaning the glasses with hot water (Choice B) can damage them, and using a paper towel (Choice C) can scratch the lenses. Storing the glasses on the bedside table (Choice D) can lead to misplacement or damage. Therefore, the most appropriate action is to store the glasses in a labeled case.

5. A client is 2 hours postoperative following a cholecystectomy. Which of the following interventions should the nurse implement?

• A. Place the client in a supine position
• B. Administer morphine for pain relief
• C. Apply a warm compress to the incision site
• D. Place a pillow under the client's knees

Correct answer: B

Rationale: Administering morphine for pain relief is crucial for postoperative clients following a cholecystectomy to manage pain effectively. Placing the client in a supine position may not be ideal as it can cause discomfort and hinder breathing. Applying a warm compress to the incision site can increase the risk of infection. Placing a pillow under the client's knees is not a priority intervention compared to pain management.

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