Nursing Elites

1. A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

• A. Clean sutures along the incision site.
• B. Grasp the knot of the sutures with forceps.
• C. Cut the sutures close to the skin on one side.
• D. Pull out the sutures with forceps in one piece.

Correct answer: A

Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.

2. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most appropriate?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit during the treatment process
• D. Refer her to a support group for family members of those with terminal cancer

Correct answer: A

Rationale: In this situation, it is crucial to involve the wife in the care of the client to provide support and empower her. Asking the wife how she would like to participate allows her to be actively involved in decision-making and caregiving. Providing information about hospice (choice B) might be premature as the couple may still be digesting the diagnosis. Encouraging the wife to visit during the treatment process (choice C) may not address her immediate need for involvement and support. Referring her to a support group for family members (choice D) is helpful but involving her directly in the client's care is a more immediate and personalized approach.

3. A client with lower extremity weakness is being taught a four-point crutch gait by a nurse. Which of the following instructions should the nurse include in the teaching?

• A. Bear weight on both legs.
• B. Move the crutches and the weak leg in unison.
• C. Advance the crutches and the strong leg simultaneously.
• D. Move the crutches forward, then move one leg at a time.

Correct answer: D

Rationale: The correct technique for a four-point crutch gait involves moving the crutches forward, then moving one leg at a time. This method provides stability and support by alternating movement between the crutches and legs. Choice A is incorrect because bearing weight on both legs simultaneously is not the correct method for a four-point gait. Choice B is incorrect as moving the crutches and weak leg together does not provide the required stability. Choice C is incorrect as advancing the crutches and strong leg together does not promote the alternating movement needed for a four-point gait.

4. When assisting an older adult client with dysphagia following a CVA during mealtime, what should the nurse prioritize?

• A. Offer the client tart or sour foods.
• B. Ensure the client is sitting upright while eating.
• C. Provide soft and easily swallowable foods.
• D. Give the client thickened liquids to help with swallowing.

Correct answer: B

Rationale: The correct answer is to ensure the client is sitting upright while eating. This position helps prevent aspiration and facilitates swallowing. Offering tart or sour foods (Choice A) may not be suitable for someone with dysphagia as they can be difficult to swallow and may increase the risk of aspiration. Providing soft and easily swallowable foods (Choice C) is crucial for individuals with swallowing difficulties. While giving thickened liquids (Choice D) is a common intervention for dysphagia, the priority during mealtime should be ensuring the client's proper positioning to support safe swallowing and prevent aspiration.

5. A client is still experiencing mild back pain after receiving analgesia 1 hour ago. Which of the following nonpharmacological pain management techniques should the nurse include in the plan?

• A. Encourage the client to apply a heating pad for 2 hours at a time
• B. Apply an ice pack to the client’s back for 1 hour
• C. Remove distractions from the client’s room
• D. Instruct the client to take deep, rhythmic breaths

Correct answer: D

Rationale: In this scenario, the nurse should instruct the client to take deep, rhythmic breaths as a nonpharmacological pain management technique. Deep, rhythmic breathing helps with relaxation and pain management, potentially reducing the perception of pain. Encouraging the client to apply a heating pad for 2 hours at a time (Choice A) is not recommended as prolonged heat application can lead to tissue damage and is not suitable for mild back pain. Applying an ice pack for 1 hour (Choice B) may not be appropriate for mild back pain as cold therapy is more commonly used for acute injuries. Removing distractions from the client’s room (Choice C) may help create a more calming environment, but it does not directly address the client's pain.

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