Nursing Elites

1. What is an appropriate teaching point for a client with left-leg weakness learning to use a cane?

• A. Maintain two points of support on the ground at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: A

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the ground at all times. This ensures stability and helps prevent falls. Choice B, using the cane on the weak side of the body, may lead to imbalance and decreased support. Choice C, advancing the cane a specific distance with each step, is not as crucial as maintaining two points of support. Choice D, advancing the cane and the strong leg simultaneously, may also compromise stability and support for the weak leg.

2. What is the most appropriate intervention for a client with phlebitis at the IV site?

• A. Apply a warm compress to the site
• B. Discontinue the IV and notify the provider
• C. Increase the IV flow rate to prevent dehydration
• D. Monitor the site for signs of infection

Correct answer: B

Rationale: The most appropriate intervention for a client with phlebitis at the IV site is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and continuing the IV can lead to complications such as infection or thrombosis. Applying a warm compress may provide symptomatic relief but does not address the root cause. Increasing the IV flow rate is not indicated and may worsen the inflammation. Monitoring for signs of infection is important, but the priority is to remove the source of inflammation by discontinuing the IV.

3. 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.

4. A client has an NG tube that needs to be irrigated every 8 hours. Which solution should the nurse use to maintain fluid and electrolyte balance?

• A. Tap water
• B. Sterile water
• C. 0.9% sodium chloride
• D. 0.45% sodium chloride

Correct answer: C

Rationale: The correct solution to maintain fluid and electrolyte balance during NG tube irrigation is 0.9% sodium chloride. This solution is isotonic and helps prevent electrolyte imbalances. Using tap water or sterile water can lead to electrolyte disturbances due to their hypotonic nature, while 0.45% sodium chloride is hypotonic and may cause further imbalances in the client's electrolyte levels.

5. How should a healthcare professional assess a patient for potential deep vein thrombosis (DVT)?

• A. Assess for unilateral leg swelling
• B. Encourage early mobilization
• C. Check for calf tenderness
• D. Observe for redness and warmth

Correct answer: A

Rationale: To assess a patient for potential deep vein thrombosis (DVT), healthcare professionals should look for unilateral leg swelling. This is a classic sign of DVT. While encouraging early mobilization is generally beneficial for preventing DVT, it is not a method of assessment. Checking for calf tenderness is also relevant but not as specific as unilateral leg swelling. Observing for redness and warmth can be signs of inflammation but are not as specific to DVT as unilateral leg swelling.

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