Nursing Elites

1. During the immediate postoperative period following a total hip replacement, which intervention is most important for the nurse to implement?

• A. Encourage the client to use a walker or cane when ambulating
• B. Keep the client's hip aligned with knees abducted
• C. Teach the client to sit on the side of the bed before standing
• D. Monitor urinary flow via an indwelling catheter

Correct answer: B

Rationale: Keeping the client's hip aligned with the knees abducted is crucial to prevent dislocation of the prosthesis, which is a priority immediately after total hip replacement surgery. This position helps maintain the stability of the new hip joint. Encouraging the client to use a walker or cane (Choice A) is important but not as critical as ensuring proper hip alignment. Teaching the client to sit on the side of the bed before standing (Choice C) is a good practice but not as essential as maintaining hip alignment. Monitoring urinary flow via an indwelling catheter (Choice D) is not directly related to preventing complications immediately after a total hip replacement.

2. Which cranial nerve is responsible for the sense of smell?

• A. Olfactory nerve
• B. Optic nerve
• C. Trigeminal nerve
• D. Vagus nerve

Correct answer: A

Rationale: The olfactory nerve (Cranial Nerve I) is indeed responsible for the sense of smell. It is located in the nasal cavity and transmits olfactory information to the brain. The optic nerve (Choice B) is responsible for vision, the trigeminal nerve (Choice C) is responsible for sensation in the face, and the vagus nerve (Choice D) is responsible for various functions such as heart rate, digestion, and speech. Therefore, the correct answer is the olfactory nerve (Choice A).

3. Which task could the nurse safely delegate to the UAP?

• A. Oral feeding of a two-year-old child after application of a hip spica cast
• B. Assessment of the placement and patency of an NG tube
• C. Participation in staff rounds to record notes regarding client goals
• D. Evaluation of a client's incisional pain following narcotic administration

Correct answer: A

Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.

4. What is an essential nursing action before administering a blood transfusion?

• A. Checking the patient’s blood pressure
• B. Verifying the blood type and patient identity with another nurse
• C. Flushing the IV line with saline
• D. Administering pre-transfusion medications

Correct answer: B

Rationale: Verifying the blood type and patient identity with another nurse is crucial before administering a blood transfusion. This step helps prevent transfusion reactions and ensures that the correct blood is given to the right patient. Checking the patient’s blood pressure, although important, is not directly related to verifying blood type and patient identity. Flushing the IV line with saline is a good practice but is not as critical as confirming the blood type and patient identity. Administering pre-transfusion medications would come after verifying the blood type and patient identity.

5. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?

• A. Altered sensory perception
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.

Similar Questions