Nursing Elites

1. The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?

• A. Begin ambulation as soon as possible.
• B. Use continuous passive motion therapy to maintain joint mobility.
• C. Avoid putting weight on the affected leg.
• D. Apply ice packs to reduce pain and swelling.

Correct answer: B

Rationale: The correct answer is B: 'Use continuous passive motion therapy to maintain joint mobility.' Continuous passive motion therapy is crucial in postoperative care following a total knee arthroplasty as it helps prevent stiffness and maintain joint mobility. Ambulation is important but should be guided and not immediate. Avoiding putting weight on the affected leg is also essential initially to prevent complications. Applying ice packs can help reduce pain and swelling, but it is not the priority instruction for maintaining joint mobility and preventing stiffness.

2. The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?

• A. Discontinue the medication immediately
• B. Increase the dose of haloperidol
• C. Complete the abnormal involuntary movement scale (AIMS)
• D. Monitor the client for signs of agitation

Correct answer: C

Rationale: These symptoms are characteristic of tardive dyskinesia, a side effect of long-term antipsychotic use. The nurse should assess the severity of these movements using the AIMS scale and report to the healthcare provider for further management. Discontinuing the medication abruptly (Choice A) can lead to withdrawal symptoms and worsening of the condition. Increasing the dose of haloperidol (Choice B) can exacerbate the symptoms of tardive dyskinesia. Monitoring for signs of agitation (Choice D) is important but does not address the specific side effect described.

3. A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?

• A. Social isolation related to hearing loss
• B. Risk for injury related to vertigo
• C. Impaired verbal communication
• D. Impaired hearing related to ear disease

Correct answer: B

Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.

4. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

• A. White blood cell count
• B. Hemoglobin
• C. Serum creatinine
• D. Culture for sensitive organisms

Correct answer: D

Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.

5. A client with hyperparathyroidism is preparing for surgery. Which preoperative lab finding is most important to report?

• A. Elevated serum calcium.
• B. Decreased serum albumin.
• C. Elevated serum potassium.
• D. Elevated serum magnesium.

Correct answer: A

Rationale: The correct answer is A: Elevated serum calcium. In hyperparathyroidism, elevated calcium levels can lead to complications such as kidney stones, bone pain, and fractures. During surgery, high calcium levels can affect neuromuscular function, cardiac function, and blood clotting. Therefore, it is crucial to report elevated serum calcium levels preoperatively to prevent potential surgical complications. Choices B, C, and D are not directly associated with hyperparathyroidism and are less likely to impact the surgical outcome in this scenario.

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