Nursing Elites

1. The nurse is caring for a client postoperatively following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?

• A. Keep the client in a low Fowler's position
• B. Maintain hip abduction with pillows
• C. Encourage early ambulation
• D. Place the client in a prone position

Correct answer: B

Rationale: Maintaining hip abduction with pillows is crucial in preventing dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and reduces the risk of the prosthesis becoming displaced. Choices A, C, and D are not as effective in preventing dislocation. Keeping the client in a low Fowler's position does not provide the necessary hip support. While early ambulation is important for circulation and preventing complications, maintaining hip abduction is more specific to preventing prosthesis dislocation. Placing the client in a prone position can increase the risk of hip prosthesis dislocation due to the extreme positioning.

2. A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?

• A. Explain that all staff are doing their best
• B. Ask for a description of what happened during the night
• C. Tell the daughter to talk to the unit's nurse manager
• D. Reassure the daughter that the mother will get better care

Correct answer: B

Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.

3. The nurse is preparing to administer a tuberculin skin test (TST). Which area of the body is the preferred site for this injection?

• A. Deltoid muscle
• B. Inner forearm
• C. Abdomen
• D. Thigh

Correct answer: B

Rationale: The inner forearm is the preferred site for administering a tuberculin skin test (TST) due to its easy accessibility, minimal hair interference, and good visibility of the injection site, allowing for accurate interpretation of the test results. The deltoid muscle, abdomen, and thigh are not preferred sites for a TST as they may not provide the optimal conditions required for the test. The deltoid muscle is commonly used for intramuscular injections, the abdomen may have varying subcutaneous fat thickness affecting the test, and the thigh may not provide the necessary visibility for accurate reading.

4. A client with heart failure is prescribed a low-sodium diet. The nurse notices the client's meal tray contains high-sodium foods. What action should the nurse take?

• A. Educate the client about the importance of a low-sodium diet
• B. Replace the meal with a low-sodium option
• C. Report the error to the dietary department
• D. Encourage the client to avoid eating the high-sodium foods

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to replace the high-sodium meal with a low-sodium option. This immediate intervention ensures that the client adheres to the prescribed low-sodium diet, crucial for managing heart failure and preventing fluid retention. Educating the client (Choice A) about the diet is important but not as urgent as ensuring they receive the correct meal. Reporting the error to the dietary department (Choice C) can be done after addressing the immediate issue. Encouraging the client to avoid high-sodium foods (Choice D) is not as effective as replacing the current meal with a suitable alternative.

5. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which laboratory finding is most indicative of this condition?

• A. Serum glucose of 180 mg/dL
• B. Blood pH of 7.30
• C. Positive urine ketones
• D. Serum bicarbonate of 25 mEq/L

Correct answer: C

Rationale: The correct answer is C: Positive urine ketones. In diabetic ketoacidosis (DKA), the body breaks down fat for energy due to a lack of insulin, leading to ketone production. Positive urine ketones are a hallmark laboratory finding in DKA as they directly reflect the presence of ketosis. Choice A, serum glucose of 180 mg/dL, may be elevated in DKA, but it is not specific to this condition. Choice B, blood pH of 7.30, often shows acidosis in DKA, but urine ketones are more specific to the presence of ketosis. Choice D, serum bicarbonate of 25 mEq/L, would typically be low in DKA due to acidosis rather than elevated.

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