Nursing Elites

1. The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?

• A. Place an abduction pillow between the client's legs.
• B. Use an abduction pillow between the client's legs.
• C. Encourage the client to cross their legs while sitting.
• D. Encourage the client to sit upright for long periods.

Correct answer: B

Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.

2. A client is receiving IV antibiotic therapy for sepsis. Which assessment finding indicates that the client's condition is improving?

• A. Urine output increases to 25 mL/hour
• B. Client reports feeling less fatigued
• C. Heart rate decreases from 120 to 110 beats per minute
• D. White blood cell count decreases from 15,000 to 9,000/mm3

Correct answer: D

Rationale: The correct answer is D. A decrease in white blood cell count indicates that the infection is responding to treatment, making this the most objective indicator of improvement in a client with sepsis. Choices A, B, and C are subjective indicators and may not always directly correlate with the resolution of the underlying infection. While an increase in urine output, a client reporting feeling less fatigued, and a decrease in heart rate are positive signs, they are not as specific or directly related to the resolution of the infection as a decrease in white blood cell count.

3. A client is admitted with a severe burn injury. What is the nurse's priority intervention?

• A. Monitor the client's urine output.
• B. Administer intravenous fluids.
• C. Apply cool, moist compresses to the burn area.
• D. Cover the burn area with a sterile dressing.

Correct answer: B

Rationale: The correct answer is B: Administer intravenous fluids. In a client with severe burn injury, the priority intervention is to administer intravenous fluids to prevent shock. Monitoring urine output (Choice A) is important but not the priority. Applying cool, moist compresses (Choice C) can be beneficial but is not the priority over fluid resuscitation. Covering the burn area with a sterile dressing (Choice D) is important for wound care but is not the immediate priority in managing severe burns.

4. When monitoring tissue perfusion following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate the closest proximal pulse.
• B. Observe the color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: Evaluating the closest proximal pulse is essential when monitoring tissue perfusion post-amputation. This pulse provides crucial information about the circulation and perfusion to the limb. Observing the color and amount of wound drainage (Choice B) is more related to wound healing assessment rather than tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or infection but is not the most direct assessment of tissue perfusion. Assessing skin elasticity of the stump (Choice D) is important for skin integrity but does not directly reflect tissue perfusion.

5. A client with pneumonia is prescribed antibiotics. What is the most important teaching point for the nurse to provide?

• A. Instruct the client to rest as much as possible.
• B. Encourage increased fluid intake to thin secretions.
• C. Explain the importance of completing the entire course of antibiotics.
• D. Instruct the client to stop taking antibiotics once symptoms subside.

Correct answer: C

Rationale: The correct answer is C. Antibiotics must be taken for the entire prescribed duration to ensure that the infection is completely eradicated. Stopping antibiotics early, even if symptoms improve, can lead to a recurrence of the infection or antibiotic resistance. Choice A is incorrect because though rest is important, completing the antibiotic course is crucial. Choice B is incorrect as while hydration is beneficial, completing the antibiotics is the priority. Choice D is incorrect as stopping antibiotics prematurely can have negative consequences.

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