Nursing Elites

1. Inspiratory and expiratory stridor may be heard in a client who:

• A. Is experiencing an exacerbation of goiter
• B. Is experiencing an acute asthmatic attack
• C. Has aspirated a piece of meat
• D. Has severe laryngotracheitis

Correct answer: D

Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.

2. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?

• A. Avoid crossing your legs at the knees or ankles.
• B. Do not sleep on the side of the hip that was operated on.
• C. Sit in high chairs and keep your knees higher than your hips.
• D. Do not bend forward at the waist to pick up objects.

Correct answer: A

Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.

3. A client is post-operative day two from a total hip arthroplasty. The nurse notices the surgical wound is red and warm to the touch. What is the most appropriate action?

• A. Apply an ice pack to the incision site.
• B. Monitor the client's temperature.
• C. Document the findings and continue to monitor.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct action when a nurse notices redness and warmth at the surgical wound post total hip arthroplasty is to notify the healthcare provider. These signs may indicate an infection, and prompt evaluation by the healthcare provider is crucial to initiate appropriate treatment. Applying an ice pack (Choice A) may not address the underlying issue of a potential infection. Monitoring the client's temperature (Choice B) is important but not the priority when signs of infection are present. Documenting the findings and continuing to monitor (Choice C) is necessary but should be accompanied by notifying the healthcare provider for further assessment and intervention.

4. A client is recovering from abdominal surgery and has a nasogastric (NG) tube in place. The nurse notes that the client is experiencing nausea despite the NG tube being patent. What is the nurse's best action?

• A. Increase the suction on the NG tube.
• B. Administer an antiemetic as prescribed.
• C. Irrigate the NG tube with saline.
• D. Reposition the client to the left side.

Correct answer: B

Rationale: Administering an antiemetic as prescribed is the best action for the nurse to take when a client with a patent NG tube is experiencing nausea. This intervention can help relieve nausea effectively. Increasing suction on the NG tube (Choice A) may not address the underlying cause of the nausea and could potentially lead to complications. Irrigating the NG tube with saline (Choice C) is not indicated for addressing nausea in this scenario. Repositioning the client to the left side (Choice D) is not the priority intervention for nausea in a client with a patent NG tube.

5. The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately?

• A. Swollen and discolored penile shaft
• B. Prepuce extends over the head of the penis
• C. Leaking urine around the top of the catheter
• D. Moist and excoriated perineal skin folds

Correct answer: A

Rationale: The correct answer is A: Swollen and discolored penile shaft. Swelling and discoloration of the penile shaft may indicate an infection or other complications requiring immediate attention. Prompt reporting allows for timely intervention to prevent further harm to the client. Choice B is incorrect because the prepuce extending over the head of the penis is not an urgent issue. Choice C, leaking urine around the catheter, may require intervention but is not as urgent as the swelling and discoloration described in choice A. Choice D, moist and excoriated perineal skin folds, also needs attention but is not as concerning as the potential complications indicated by the findings in choice A.

Similar Questions