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 client has a new diagnosis of hypertension and is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

• A. Increase your sodium intake to 3,000 mg per day.
• B. Exercise for 30 minutes at least 5 days a week.
• C. Sleep for at least 10 hours each night.
• D. Limit your fluid intake to 1 liter per day.

Correct answer: B

Rationale: The correct answer is B: "Exercise for 30 minutes at least 5 days a week." Regular exercise helps promote cardiovascular health and manage hypertension. Choice A is incorrect because increasing sodium intake is not recommended for hypertension. Choice C is incorrect because while sleep is important, excessive sleep duration is not typically part of hypertension management. Choice D is incorrect because fluid intake should be adequate unless advised otherwise by a healthcare provider.

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

• A. Increased appetite
• B. Pallor
• C. Tachycardia
• D. Hypertension

Correct answer: B

Rationale: The correct answer is B: Pallor. Pallor, which is paleness of the skin, is a common sign of anemia due to a decreased number of red blood cells or hemoglobin levels. This results in reduced oxygen-carrying capacity, leading to the paleness of the skin. Choice A, increased appetite, is not typically associated with anemia. Choice C, tachycardia (increased heart rate), can be present in anemia as the body compensates for decreased oxygenation. Choice D, hypertension (high blood pressure), is not a common finding in anemia; instead, low blood pressure may be observed due to decreased blood volume.

4. A nurse is caring for a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous wound drainage
• B. Heart rate of 90/min
• C. Urine output of 30 mL/hr
• D. Temperature of 37.3°C (99.1°F)

Correct answer: C

Rationale: A urine output of 30 mL/hr is significantly low and indicates possible renal impairment or inadequate perfusion to the kidneys, which are critical for postoperative recovery. In this situation, decreased urine output could lead to fluid and electrolyte imbalances, affecting the client's overall condition. The nurse should report this finding promptly to the healthcare provider for further evaluation and intervention. Serosanguineous wound drainage is a normal finding in the early postoperative period and does not typically warrant immediate concern. A heart rate of 90/min is within the normal range and may be expected in a postoperative client due to the stress response. A temperature of 37.3°C (99.1°F) is slightly elevated but not a concerning finding in isolation postoperatively.

5. A nurse is developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the nurse include?

• A. Administer calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit light exposure to the infusion.
• D. Keep the client on NPO status.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.

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