Nursing Elites

1. The nurse is caring for a client who underwent a total knee replacement yesterday. What activity level should the nurse encourage today?

• A. Bed rest with bathroom privileges only
• B. Frequent, short walks with assistance
• C. Range of motion exercises to the knee every four hours
• D. Leg elevation to reduce swelling

Correct answer: B

Rationale: After a total knee replacement, early ambulation is crucial for promoting circulation and preventing complications like thrombosis. Bed rest should be avoided as it can increase the risk of complications. Range of motion exercises are important but should be performed gradually and not excessively. Leg elevation is beneficial for reducing swelling but should not be the primary activity level encouraged immediately after surgery.

2. The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse?

• A. The child looks at the floor when answering the nurse's questions
• B. The mother's version of the injury is different from the child's version
• C. The child has several abrasions on the chest and legs
• D. The mother refuses to answer questions about family history

Correct answer: B

Rationale: In cases of possible child abuse, discrepancies between the accounts given by the child and the parent are critical indicators. This inconsistency could suggest that the injury was not accidental and may be a result of abuse. Looking at the floor while answering questions or having abrasions on the body can be concerning but are not as direct indicators of abuse as conflicting stories between the child and the parent.

3. A client with a diagnosis of myocardial infarction (MI) is prescribed nitroglycerin. What is the primary action of this medication?

• A. Increases heart rate
• B. Lowers blood pressure
• C. Dilates coronary arteries
• D. Reduces myocardial oxygen demand

Correct answer: C

Rationale: The correct answer is C: Nitroglycerin dilates coronary arteries, improving blood flow to the heart muscle. This helps increase oxygen supply to the heart tissue. Option A, 'Increases heart rate,' is incorrect because nitroglycerin does not directly affect heart rate. Option B, 'Lowers blood pressure,' is also incorrect as while nitroglycerin can lower blood pressure, its primary action in the context of MI is related to coronary artery dilation. Option D, 'Reduces myocardial oxygen demand,' is not the primary action of nitroglycerin in the treatment of myocardial infarction; its main action is to increase oxygen supply by dilating coronary arteries.

4. A client with chronic kidney disease is being evaluated for dialysis. Which laboratory value would be most concerning to the nurse?

• A. Hemoglobin 9.5 g/dL
• B. Potassium 6.2 mEq/L
• C. Creatinine 3.5 mg/dL
• D. BUN 50 mg/dL

Correct answer: B

Rationale: The correct answer is B: Potassium 6.2 mEq/L. In chronic kidney disease, the kidneys struggle to regulate potassium levels, leading to hyperkalemia. A potassium level of 6.2 mEq/L is dangerously high and can cause life-threatening cardiac arrhythmias. Hemoglobin of 9.5 g/dL may indicate anemia, which is common in chronic kidney disease but is not immediately life-threatening. Creatinine and BUN levels are markers of kidney function; although elevated levels indicate kidney impairment, they are not acutely life-threatening like severe hyperkalemia.

5. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?

• A. Stand the client to void and run tap water within hearing distance before catheterizing
• B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
• C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
• D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon

Correct answer: D

Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

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