Nursing Elites

1. A client who is 1 day postoperative following a total hip arthroplasty should be instructed to do which of the following?

• A. Avoid using a walker while walking.
• B. Keep the hip flexed at 90° while sitting.
• C. Place a pillow between your legs when turning.
• D. Cross your legs at the ankles when sitting.

Correct answer: C

Rationale: Placing a pillow between the legs is essential post-total hip arthroplasty to prevent adduction of the hip joint, reducing the risk of dislocation. Choices A, B, and D are incorrect. Using a walker while walking is encouraged for support and stability. Keeping the hip flexed at 90° while sitting can increase the risk of hip dislocation. Crossing legs at the ankles when sitting may also lead to hip dislocation.

2. A client is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

• A. The client is experiencing an adverse reaction to rifampin.
• B. The client's seizure disorder is no longer under control.
• C. The client is showing evidence of phenytoin toxicity.
• D. The client is having adverse effects due to combination antimicrobial therapy.

Correct answer: C

Rationale: Ataxia and incoordination are signs of phenytoin toxicity rather than adverse reactions to rifampin or isoniazid. These symptoms indicate that the client is experiencing an adverse effect of phenytoin, requiring a dose adjustment. Choice A is incorrect because rifampin is not typically associated with ataxia and incoordination. Choice B is incorrect as the development of ataxia and incoordination does not necessarily mean the seizure disorder is no longer under control. Choice D is incorrect as the symptoms are more indicative of phenytoin toxicity rather than adverse effects of combination antimicrobial therapy.

3. A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?

• A. Clamp the chest tube
• B. Maintain the drainage below the level of the chest
• C. Elevate the chest tube above chest level
• D. Avoid frequent dressing changes

Correct answer: B

Rationale: The correct intervention for a client with a chest tube connected to a closed drainage system is to maintain the drainage below the level of the chest. This position allows proper drainage of fluids and helps prevent complications such as backflow of blood or fluids into the chest cavity. Clamping the chest tube (Choice A) is incorrect as it can lead to a tension pneumothorax. Elevating the chest tube above chest level (Choice C) is also incorrect because it can impede proper drainage. Avoiding frequent dressing changes (Choice D) is important to prevent introducing infection, but it is not directly related to the position of the drainage system.

4. What is the nurse's responsibility when managing a physically assaultive client?

• A. Restrict the client to the room
• B. Place the client under one-to-one supervision
• C. Restore the client's self-control
• D. Clear the area of other clients

Correct answer: C

Rationale: The correct answer is C: Restore the client's self-control. When managing a physically assaultive client, the nurse's responsibility is to help the client regain control over their actions and emotions. This is crucial in preventing harm to themselves and others. Restricting the client to the room (Choice A) may escalate the situation and is not a therapeutic approach. Placing the client under one-to-one supervision (Choice B) is important for safety but does not address the root cause of the behavior. Clearing the area of other clients (Choice D) is necessary for safety but does not directly address the client's self-control. Therefore, the priority in managing an assaultive client is to focus on restoring their self-control.

5. A nurse is caring for a client who is experiencing a situational crisis following the loss of a job. The client states, 'I don't think I can go through this again.' Which of the following actions is the nurse's priority?

• A. Refer the client to a mental health counselor
• B. Encourage the client to express their feelings
• C. Determine if the client is experiencing psychotic thinking
• D. Ask the client about their social support system

Correct answer: C

Rationale: In this situation, the nurse's priority is to determine if the client is experiencing psychotic thinking as it addresses the immediate safety concern. Psychotic thinking may pose a risk to the client's safety or the safety of others. Referring the client to a mental health counselor (choice A) may be appropriate but not the priority when safety is a concern. Encouraging the client to express their feelings (choice B) and asking about their social support system (choice D) are essential aspects of care but are secondary to addressing immediate safety issues.

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