Nursing Elites

1. The nurse is caring for a postoperative client who is reluctant to ambulate. What strategy should the nurse use to encourage the client?

• A. Explain the benefits of ambulation for recovery
• B. Wait for the client to request to walk
• C. Tell the client that walking is necessary for discharge
• D. Offer pain medication before walking

Correct answer: A

Rationale: Corrected Rationale: The correct strategy for the nurse to encourage the postoperative client to ambulate is to explain the benefits of ambulation for recovery. Educating the client on how ambulation aids in preventing complications and promotes faster recovery can motivate their participation. Choice B is incorrect because waiting for the client to request to walk may lead to delays in mobilization. Choice C is incorrect as it may induce unnecessary fear in the client. Choice D is incorrect as offering pain medication before walking does not address the client's reluctance to ambulate.

2. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?

• A. Instruct the client to sit or lie down
• B. Monitor blood pressure and pulse
• C. Administer an anti-dizziness medication
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.

3. The nurse is providing discharge teaching to a client with newly diagnosed type 2 diabetes mellitus. Which instruction is most important to prevent complications?

• A. Monitor blood glucose levels regularly
• B. Maintain a low-fat diet
• C. Exercise regularly
• D. Take medication as prescribed

Correct answer: A

Rationale: Regular monitoring of blood glucose levels is crucial in managing diabetes and preventing complications. This allows the client and healthcare team to make timely adjustments to the treatment plan. While maintaining a low-fat diet, exercising regularly, and taking medication as prescribed are all important aspects of diabetes management, monitoring blood glucose levels takes precedence as it provides real-time information about the client's condition and helps prevent acute complications.

4. A client is being treated for heart failure. What should the nurse monitor to evaluate treatment effectiveness?

• A. Daily weight
• B. Electrolyte levels
• C. Urine output
• D. All of the above

Correct answer: D

Rationale: Monitoring daily weight, electrolyte levels, and urine output is crucial in evaluating treatment effectiveness for heart failure. Daily weight monitoring helps assess fluid retention or loss, changes in electrolyte levels can indicate imbalances affecting heart function, and urine output monitoring provides insights into kidney function and fluid balance. Therefore, all options are essential components in assessing the patient's fluid status and response to treatment, making 'All of the above' the correct answer. Choices A, B, and C are incorrect individually as they only represent partial aspects of monitoring heart failure treatment effectiveness.

5. The nurse is caring for a client who has just undergone a total hip replacement. Which intervention is most important to prevent postoperative complications?

• A. Encourage early ambulation
• B. Apply ice to the surgical site
• C. Monitor the surgical site for signs of infection
• D. Administer pain medication as prescribed

Correct answer: A

Rationale: Encouraging early ambulation is crucial following a total hip replacement surgery as it helps prevent complications such as deep vein thrombosis (DVT) by promoting circulation. Early ambulation also aids in preventing pneumonia, muscle atrophy, and pressure ulcers. Applying ice to the surgical site may help with pain and swelling, but it is not as critical in preventing complications as early ambulation. While monitoring the surgical site for signs of infection is important, it is not as crucial in preventing postoperative complications compared to early ambulation. Administering pain medication as prescribed is essential for comfort and pain management but does not directly prevent postoperative complications like early ambulation does.

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