Nursing Elites

1. A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?

• A. The client advances the cane 18 inches in front of the foot
• B. The client holds the cane in the left hand
• C. The client advances the cane and the right leg simultaneously
• D. The client holds the cane with the elbow flexed at 60°

Correct answer: B

Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.

2. When providing discharge instructions for a client prescribed home oxygen, what is an essential safety measure?

• A. Ensure the client has cotton bedding
• B. Keep the oxygen equipment away from heat sources
• C. Use wool blankets to ensure warmth
• D. Allow the client to use electronic devices near the oxygen supply

Correct answer: B

Rationale: The correct answer is B: 'Keep the oxygen equipment away from heat sources.' Placing oxygen equipment near heat sources can lead to fire hazards due to the flammability of oxygen. Cotton bedding or wool blankets are not directly related to oxygen safety measures. Allowing electronic devices near the oxygen supply can increase the risk of fire due to potential sparks or heat generated.

3. A nurse is teaching a client who has multiple sclerosis (MS) about strategies to reduce fatigue. Which of the following instructions should the nurse include?

• A. Exercise to the point of exhaustion
• B. Rest as needed throughout the day
• C. Avoid physical activity
• D. Exercise only once per week

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Rest as needed throughout the day.' Fatigue is a common symptom of multiple sclerosis (MS), and adequate rest is essential to manage it effectively. Resting as needed helps conserve energy and prevent fatigue from worsening. Choices A, C, and D are incorrect. 'Exercise to the point of exhaustion' is not recommended as it can lead to increased fatigue. 'Avoiding physical activity' entirely is not advisable as appropriate exercise can help maintain strength and energy levels. 'Exercising only once per week' may not be sufficient to combat fatigue and maintain overall well-being in clients with MS.

4. Which of the following interventions should the nurse implement for a client with dementia who is at risk of falling?

• A. Keep the bed in the lowest position
• B. Raise all four side rails to prevent falls
• C. Assist with ambulation every 2 hours
• D. Use a bed exit alarm to notify staff of attempts to leave the bed

Correct answer: D

Rationale: The correct intervention for a client with dementia at risk of falling is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention helps in preventing falls by alerting the staff when the client tries to get out of bed. Keeping the bed in the lowest position (Choice A) may not prevent falls and could make it challenging for staff to provide care. Raising all four side rails (Choice B) can be a restraint and is not recommended as it may lead to entrapment or other risks. Assisting with ambulation every 2 hours (Choice C) may not be feasible or effective in preventing falls, as the client may attempt to get out of bed at any time.

5. How should a healthcare provider assess a patient for fluid overload?

• A. Monitor weight and assess for shortness of breath
• B. Auscultate lung sounds and monitor blood pressure
• C. Assess for edema in the extremities
• D. Assess for jugular venous distension

Correct answer: A

Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.

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