Extract:

Question 1 of 5

A nurse is assisting with the care of a client who is postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

A. Place the client in a prone position.B. Monitor the client for signs of dislocation.C. Instruct the client to keep the affected leg in a dependent position.D. Apply a cold compress to the surgical site every 4 hr.

Correct Answer: B

Rationale: Dislocation is a risk post-hip arthroplasty, requiring monitoring (e.g., leg positioning). Prone isn't standard, dependent positioning risks swelling, and cold compresses are as needed.

Question 2 of 5

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A. A nurse observes a client vomiting after receiving an oral pain medication.B. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm.C. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client.D. A nurse discovers that a client's family member has administered a PCA dose.

Correct Answer: C

Rationale: An IV pump error delivering double the fluid is a serious medication error requiring an incident report. Vomiting is a side effect, restraint removal may not need reporting, and PCA misuse needs clarification.

Question 3 of 5

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

A. Memory loss that disrupts ADLsB. CatatoniaC. IllusionsD. Pressured speech

Correct Answer: A

Rationale: Dementia typically involves memory loss severe enough to disrupt activities of daily living (ADLs), unlike catatonia, illusions, or pressured speech, which aren't defining features.

Question 4 of 5

A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

A. Warm the dialysate solution to 45Â°C (113Â°F).B. Monitor the client for signs of peritonitis.C. Add heparin to the dialysate solution per standing orders.D. Flush the catheter with dextrose 5% in water between exchanges.

Correct Answer: B

Rationale: Monitoring for peritonitis (e.g., cloudy effluent, pain) is key in peritoneal dialysis. Dialysate is warmed to body temp (37Â°
C), heparin may be added, and saline flushes are used.

Question 5 of 5

A nurse is reinforcing teaching with a client who has a new prescription for venlafaxine. Which of the following statements should the nurse include?

A. You should take this medication on an empty stomach.B. You might notice an increase in your blood pressure.C. This medication might cause your skin to turn yellow.D. You should stop taking this medication if you feel better.

Correct Answer: B

Rationale: Venlafaxine can increase blood pressure, requiring monitoring. It's taken with food, doesn't cause jaundice, and stopping abruptly risks withdrawal.