Nursing Elites

1. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)

• A. A client on birth control pills
• B. A client who is immobile
• C. A client on an anticoagulant
• D. A client with dementia who has been wandering

Correct answer: a

Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.

2. The nurse uses proper body mechanics to move a client up in bed. What action by the nurse will increase their risk of a workplace injury?

• A. Place the bed in the lowest possible position
• B. Use the legs when lifting
• C. Keep feet apart to provide a wide base of support
• D. Face the direction of the movement

Correct answer: A

Rationale: Placing the bed in the lowest possible position increases the risk of injury because it does not support proper body mechanics. When lifting a client, it is important to have the bed at a comfortable height to avoid strain. Using the legs when lifting (choice B) is correct as it reduces the strain on the back. Keeping feet apart to provide a wide base of support (choice C) helps with stability and balance. Facing the direction of the movement (choice D) is essential for maintaining proper alignment and reducing the risk of injury.

3. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?

• A. Once retinal detachment occurs, it does not return to its normal state
• B. Once the tissue has necrosed from high-pressure, it does not regenerate
• C. Glaucoma always leads to permanent blindness
• D. Once bacterial infection has caused damage, the tissue does not regenerate

Correct answer: B

Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.

4. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

• A. The UAP puts shoes on the client
• B. The UAP removes floor rugs and loose objects from the path
• C. The UAP walks to the side and slightly in front of the client
• D. The UAP uses a transfer (gait) belt

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

5. A client has a new arm cast. What is incorrect teaching by the nurse?

• A. Use a sling to alleviate fatigue
• B. Elevate the arm above the heart to reduce swelling
• C. Report ‘hot spots’ felt under the cast
• D. Sudden increase in drainage is expected

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

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