Nursing Elites

1. A client with left-leg weakness is learning to use a cane. Which teaching point is most appropriate?

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

Correct answer: B

Rationale: The correct teaching point is to maintain two points of support on the ground at all times when using a cane. This ensures stability and helps distribute weight evenly. Choice A is incorrect because the cane should be used on the stronger side of the body to provide support to the weaker leg. Choice C is incorrect as advancing the cane too far with each step can lead to imbalance. Choice D is incorrect as advancing the cane and the strong leg simultaneously may not provide adequate support for the weaker leg.

2. What is the initial step a nurse should take when irrigating a wound?

• A. Wear sterile gloves while removing the old dressing
• B. Cleanse the wound from the center outward
• C. Apply a warm compress to the wound
• D. Use a 20 mL syringe to irrigate the wound

Correct answer: B

Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.

3. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

• A. Ignore the client's decision and proceed
• B. Report the situation to the provider
• C. Ask the family to convince the client
• D. Reassess the need for surgery with the client

Correct answer: B

Rationale: The correct action for the nurse to take is to report the client's decision to the provider who obtained informed consent. This ensures that the provider is informed of the client's change in decision and can discuss the situation further with the client. Choice A is incorrect as ignoring the client's decision is not appropriate and goes against the principles of patient autonomy. Choice C is incorrect because involving the family in convincing the client can be coercive and may not respect the client's autonomy. Choice D is incorrect because the nurse should not re-sign the informed consent form without the client's consent and a discussion with the provider.

4. What is the proper technique for obtaining a blood specimen from a central venous line?

• A. Use sterile gloves and discard the first 10 mL of blood
• B. Flush the line with heparin and then draw the specimen
• C. Draw the specimen and then administer heparin
• D. Use non-sterile gloves to reduce contamination risk

Correct answer: A

Rationale: The correct technique for obtaining a blood specimen from a central venous line is to use sterile gloves and discard the first 10 mL of blood. This practice helps ensure that the blood sample collected is not contaminated. Choice B is incorrect because flushing the line with heparin before drawing the specimen can contaminate the sample. Choice C is incorrect as administering heparin before drawing the specimen can affect the accuracy of the blood sample. Choice D is incorrect as using non-sterile gloves increases the risk of contamination, which is not recommended when obtaining a blood specimen from a central venous line.

5. Which of the following actions should the nurse take to ensure the safety of a client using home oxygen?

• A. Allow smoking in designated areas
• B. Keep oxygen tanks upright at all times
• C. Store the oxygen equipment in a closet
• D. Keep oxygen tanks at least 10 feet away from heat sources

Correct answer: B

Rationale: The correct answer is B: 'Keep oxygen tanks upright at all times.' Oxygen tanks should be stored in an upright position to prevent leaks and accidents. Choice A is incorrect as smoking should never be allowed near oxygen due to the risk of fire. Choice C is incorrect as oxygen equipment should be stored in a well-ventilated area, not in a closet. Choice D is incorrect as oxygen tanks must be kept a minimum of 5 to 10 feet away from heat sources to prevent combustion. Therefore, the best practice is to keep oxygen tanks upright to ensure safety.

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