Nursing Elites

1. A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

• A. When do you usually bathe, in the morning or evening?
• B. Do you prefer a bath or a shower?
• C. At what temperature do you prefer your bath water?
• D. Are you able to help with your hygiene care?

Correct answer: D

Rationale: The priority assessment question before beginning hygiene care for a new resident is determining if the resident is able to help with their hygiene care. This is essential to ensure the resident's safety during the procedure and prevent any potential injuries. Options A, B, and C, while relevant to providing personalized care, are not as critical as assessing the resident's ability to participate in their own hygiene care. Asking about the resident's ability to assist also promotes their independence and autonomy in self-care activities.

2. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client's nose and mouth.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

3. A client is admitted with acute pyelonephritis. Which symptom should the nurse expect the client to report?

• A. Flank pain
• B. Pedal edema
• C. Hypotension
• D. Weight gain

Correct answer: A

Rationale: Flank pain is a classic symptom of acute pyelonephritis, which is a bacterial infection of the kidney. It occurs due to inflammation and irritation of the renal capsule, leading to pain in the flank region. Pedal edema (swelling in the feet and ankles) is more commonly associated with conditions like heart failure or kidney disease, not typically seen in acute pyelonephritis. Hypotension (low blood pressure) is a systemic symptom that may occur with severe infections but is not a specific hallmark of pyelonephritis. Weight gain is also not a typical symptom of acute pyelonephritis; instead, patients may experience weight loss due to decreased appetite and systemic effects of infection.

4. A nurse is caring for an older, immobile patient whose condition requires a supine position. Which metabolic alteration will the nurse monitor for in this patient?

• A. Increased appetite
• B. Increased diarrhea
• C. Increased metabolic rate
• D. Increased pulse rate

Correct answer: D

Rationale: When an older, immobile patient is in a supine position, it increases cardiac workload, leading to an increased pulse rate. This is because the heart rate in older adults may not tolerate the additional workload. Choices A, B, and C are incorrect because an increased appetite, increased diarrhea, and increased metabolic rate are not directly associated with being immobile in a supine position. Increased appetite is more related to nutritional needs or certain medical conditions, increased diarrhea could be due to various causes, and an increased metabolic rate is not typically a direct consequence of lying supine.

5. A client with a left leg cast is being taught how to use crutches. Which of the following statements should indicate to the nurse that the client understands the teaching?

• A. When descending stairs, I will first shift my weight to my right (unaffected) leg.
• B. I will use crutches to support my weight on my left leg.
• C. When ascending stairs, I will lead with my left leg.
• D. I will keep my crutches under my arms for support.

Correct answer: A

Rationale: The correct answer is A. Shifting weight to the unaffected leg when descending stairs is crucial for maintaining balance and safety. This technique helps prevent falls and distributes weight appropriately. Choices B, C, and D are incorrect because using crutches to support the weight on the injured leg, leading with the injured leg when ascending stairs, and keeping crutches under the arms are all potentially unsafe practices that could lead to further injury or accidents.

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