Nursing Elites

1. A nurse is providing discharge teaching to a client who has had a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?

• A. I will avoid sitting in a chair for longer than 30 minutes.
• B. I will avoid crossing my legs when sitting.
• C. I will bend at the hips to pick up items from the floor.
• D. I will avoid using a raised toilet seat.

Correct answer: C

Rationale: The correct answer is C because bending at the hips can dislocate the hip joint in clients who have had a total hip arthroplasty. This movement should be avoided to prevent complications post-surgery. Choices A, B, and D are all correct statements for a client who has had a total hip arthroplasty. Avoiding prolonged sitting, crossing legs, and using a raised toilet seat are all appropriate measures to ensure proper healing and prevent complications.

2. A client is receiving intermittent tube feedings and is at risk for aspiration. What should the nurse identify as a risk factor?

• A. A residual of 65mL 1 hour postprandial.
• B. History of gastroesophageal reflux disease.
• C. Receiving a high-osmolarity formula.
• D. Receiving a feeding in a supine position.

Correct answer: B

Rationale: The correct answer is B: History of gastroesophageal reflux disease. Gastroesophageal reflux disease increases the risk of aspiration due to the potential for regurgitation of stomach contents into the esophagus and airways. Choices A, C, and D are not directly related to an increased risk of aspiration. A residual of 65mL 1 hour postprandial may indicate delayed gastric emptying but is not a direct risk factor for aspiration. Receiving a high-osmolarity formula or receiving a feeding in a supine position are not specific risk factors for aspiration unless they contribute to reflux or other related issues.

3. A client in active labor is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

• A. Contractions lasting 80 seconds.
• B. FHR baseline of 170/min.
• C. Early decelerations in the FHR.
• D. Temperature of 37.4°C (99.3°F).

Correct answer: B

Rationale: The correct answer is B because a baseline FHR of 170/min indicates fetal tachycardia, which needs further evaluation. Choice A about contractions lasting 80 seconds is within the normal range for active labor. Choice C, early decelerations in the FHR, are generally considered benign and do not require immediate reporting. Choice D, a temperature of 37.4°C (99.3°F), falls within normal limits for a laboring client and does not warrant immediate reporting.

4. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take?

• A. Administer haloperidol as prescribed.
• B. Keep the client in a supine position.
• C. Administer lorazepam as prescribed.
• D. Encourage the client to drink fluids with meals.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client experiencing acute alcohol withdrawal is to administer lorazepam as prescribed. Lorazepam is a benzodiazepine used to prevent seizures and manage agitation in clients undergoing alcohol withdrawal. Administering haloperidol (Choice A) is not recommended in alcohol withdrawal as it may lower the seizure threshold. Keeping the client in a supine position (Choice B) is not specifically indicated in managing alcohol withdrawal. Encouraging the client to drink fluids with meals (Choice D) is important for hydration but does not address the acute symptoms of alcohol withdrawal.

5. A nurse is teaching a client who has iron deficiency anemia about food choices to increase iron intake. Which of the following foods should the nurse recommend?

• A. Eggs
• B. Carrots
• C. White bread
• D. Spinach

Correct answer: D

Rationale: Spinach is an excellent choice to recommend as it is rich in non-heme iron, which can help improve iron levels in clients with iron deficiency anemia. Eggs (Choice A) are a good source of protein but do not contain as much iron as spinach. Carrots (Choice B) are rich in vitamin A but are not a significant source of iron. White bread (Choice C) is not a good source of iron compared to spinach.

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